Feeding Eval | EBS Secure Forms

Parent/Guardian First Name*
Parent/Guardian Last Name*
Phone Number*
Email Address*
Child's Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
What concerns do you have about your child’s eating?
What do you hope to gain from this appointment?
General History
Is your child currently allowed to eat by mouth?
- Yes
- No
Is your child currently allowed to drink by mouth?
- Yes
- No
Does your child have any of the following symptoms when eating or drinking? (Please check all that apply.)
- Gagging/coughing
- Vomiting
- Eats a limited variety of food/selective slow weight gain
- Refuses to eat
- Spits out food
- Cries/screams
- Choking
- Limited volume/not eating enough difficulty swallowing
- Refuses to swallow/holds food in mouth
- Difficulty progressing to table food
- Does not remain seated
- Throws food and/or utensils
- Other
Please specify other:
At what age did your child’s eating first become a concern?
Has your child been seen by any other specialists/therapists to help with feeding?
- Gastroenterologist
- Ear, Nose, and Throat Doctor
- Early Interventionist
- Dietitian/Nutritionist
- Outpatient Therapist
- Speech Therapist
- Other Feeding Program
- Alternative Medicine Provider
- Other
Please specify other:
What strategies have you tried to deal with your child’s eating problems?
- Distraction during meals (e.g., games, TV)
- Skipping meals
- Rewards
- Feeding child when s/he requests food
- Coaxing
- Forcing
- Allowing child to drink more fluids
- Giving preferred foods
- Punishment
- High-calorie supplements/formula
- Other
Please specify other:
Please describe strategies selected above.
Was your baby in the NICU?
- Yes
- No
Reason for NICU stay:
Length of NICU stay:
Was your baby breast fed?
- Yes
- No
For how long?
Did you have difficulty breastfeeding?
- Yes
- No
If yes, please explain.
Did your baby ever drink formula?
- Yes
- No
What brand(s) of formula?
Did your child have difficulty bottle feeding?
- Yes
- No
If yes, please explain.

Diet Assessment
Please list everything your child might eat or drink during a typical day.
Describe all food, formula, drinks, snacks, food extras (butter, oil, salad dressing) that are offered AND the amounts actually eaten.
For example:
Stage 2 carrots: 4-ounce jar
Whole milk with heavy cream: 6 ounces + 1 tablespoon
Chewy granola bar: 1/4 of the bar
Breakfast
Food/Drink Item Amount Child Actually Eats/Drinks

Click (+) to add items.
Snack
Food/Drink Item Amount Child Actually Eats/Drinks

Click (+) to add items.
Lunch
Food/Drink Item Amount Child Actually Eats/Drinks

Click (+) to add items.
Snack
Food/Drink Item Amount Child Actually Eats/Drinks

Click (+) to add items.
Dinner
Food/Drink Item Amount Child Actually Eats/Drinks

Click (+) to add items.
Bedtime Snack
Food/Drink Item Amount Child Actually Eats/Drinks

Click (+) to add items.

Feeding Evaluation

Step 1 of 6

General History

Medical History

Eating Environment

Eating and Drinking

Food Textures

Diet Assessment

Food/Drink Item	Amount Child Actually Eats/Drinks

Food/Drink Item	Amount Child Actually Eats/Drinks

Food/Drink Item	Amount Child Actually Eats/Drinks

Food/Drink Item	Amount Child Actually Eats/Drinks