Pediatric Feeding History

Pediatric Feeding History Form

Client Information

Name(Required)
Date of Birth
Please list all previous feeding evaluations
Where
Date of evaluation
 
Has your child ever had a video-swallow study done?(Required)
Max. file size: 32 MB.
Was your child breast fed?(Required)
Was your child bottle fed?(Required)
Did your child ever have complications with breast/bottle feeding?(Required)
Does your child have a tongue/lip tie?(Required)
During early feedings, did your child (check all that apply)(Required)
For all that you checked above, please list out the following
What it was
When it would happen
Why they would happen
For how long they would happen
 

If your child eats by mouth, answer the following questions

List 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/Drink
Brand
Is this a favorite?
 
List the foods your child refuses
List the foods your child is allergic to
Describe your child's meal time
Who typically feeds your child?
Who typically eats with your child?
What type of chair is used?
How long are meals typically?
 

If your child is tube fed, please answer the following questions

List
Please detail your child's feeding schedule below
Start time of feeding
NG, G or continuous feeds
Amount. Gravity or Pump?
Over what time-period or what rate?
Does your child take anything orally
 

The following questions pertain to all children

Has your child every been on any type of special diet other than what you just described?(Required)
If yes, please describe the following
Type of diet
At what ages
What was your child's response
 
How would you describe your child's weight(Required)
Does your child have/had any of the following (check all that apply)?(Required)
Is your child under the care of a dietician and/or nutritionist?(Required)
Name of dietician and/or nutritionist
For all that you checked, please describe them in more detail here
Challenge
Description
 
Max. file size: 32 MB.

Responsible Party Information (Client or Parent/Guardian)

Name(Required)
Name(Required)