Pediatric Feeding History Pediatric Feeding History Form Today's Date(Required) Month Day Year Client InformationName(Required) First Name(Required) Last Date of Birth Month Day Year In your own words, please explain what your child's currently feeding concern?(Required) Please list all previous feeding evaluationsWhereDate of evaluation Add RemoveWhat feeding inventions have been tried in the past?(Required) Has your child ever had a video-swallow study done?(Required) Yes No If yes, when and what were the results? Please upload a file of your child's video-swallow studyMax. file size: 32 MB.Was your child breast fed?(Required) Yes No If yes, from when to when? Was your child bottle fed?(Required) Yes No If yes, from when to when? Did your child ever have complications with breast/bottle feeding?(Required) Yes No If yes, please explain your child's initial skills/concerns Does your child have a tongue/lip tie?(Required) Yes No If yes, was it resolved and what changes were observed after revision? During early feedings, did your child (check all that apply)(Required) Arch Cry Spit up Gag Cough Vomit Pull off the nipple None Other For all that you checked above, please list out the followingWhat it wasWhen it would happenWhy they would happenFor how long they would happen Add RemoveDescribe how the weaning process off the breast and/or bottle was for your child, when and if for any specific reason the child was weaned.(Required) At what age was your child introduced to baby cereal?(Required) At what age was your child introduced to baby food?(Required) At what age was your child introduced to finger foods?(Required) At what age was your child introduced to table foods?(Required) At what age did your child transition to only table foods?(Required) Please describe how these transitions were handled by your child, especially if any difficulties happened.(Required) If your child eats by mouth, answer the following questionsList out all the foods that your child currently will eat and drink. In the "is this a favorite" column, please put a Y in all the ones that are current favorites.Food/DrinkBrandIs this a favorite? Add RemoveList the foods your child refuses Add RemoveList the foods your child is allergic to Add RemoveDescribe your child's meal timeWho typically feeds your child?Who typically eats with your child?What type of chair is used?How long are meals typically? Add RemoveDoes your child use utensils or any type of special cups/bowls/straws (please describe)? Are there any other activities going on at meals? Is there a mealtime routine? Please explain. If your child is tube fed, please answer the following questionsWhat type of formula is used and how do you mix it? Describe where your child is tube fed and what activities are occurring at the same time List Add RemovePlease detail your child's feeding schedule belowStart time of feedingNG, G or continuous feedsAmount. Gravity or Pump?Over what time-period or what rate?Does your child take anything orally Add RemoveThe following questions pertain to all childrenHas your child every been on any type of special diet other than what you just described?(Required) Yes No If yes, please describe the followingType of dietAt what agesWhat was your child's response Add RemoveHow do you know your child is hungry?(Required) How do you know when your child is full?(Required) Has your child lost or gained weight in the last 6 months, and ow much?(Required) How would you describe your child's weight(Required) Ideal Underweight Overweight Does your child have/had any of the following (check all that apply)?(Required) Dental Occlusions (under/over bite, etc) Constipation Diarrhea Vomiting Choking Gagging Coughing Runny Nose or cold-like symptoms at meals Wet voice Pocketing food (holding it in their cheeks) Drooling Fevers History of pneumonia, upper respiratory infections in Reflux None of these Other Is your child under the care of a dietician and/or nutritionist?(Required) Yes No Name of dietician and/or nutritionist First Last For all that you checked, please describe them in more detail hereChallengeDescription Add RemovePlease use the space below to provide any additional information regarding your feeding concerns Upload copy of most recent growth chartMax. file size: 32 MB.Responsible Party Information (Client or Parent/Guardian)Name(Required) First Name(Required) Last Phone(Required)Email(Required)
