Feeding Evaluation Step 1 of 6 16% 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 HistoryIs your child currently allowed to eat by mouth?YesNoIs your child currently allowed to drink by mouth?YesNoDoes 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?YesNoReason for NICU stay:Length of NICU stay:Was your baby breast fed?YesNoFor how long?Did you have difficulty breastfeeding?YesNoIf yes, please explain.Did your baby ever drink formula?YesNoWhat brand(s) of formula?Did your child have difficulty bottle feeding?YesNoIf yes, please explain. Medical HistoryPlease note any of your child’s medical, developmental, and/or mental health diagnoses. GE reflux (heartburn) Failure to thrive/slow growth Pulmonary (lung) issues (asthma) Slow stomach emptying Eosinophilic esophagitis Developmental delay Cardiac (heart) issues Constipation Diarrhea Esophagitis Neurologic (brain) issues Renal (kidney) issues Autism/PDD Mental health Genetic/chromosome abnormality Other Please specify mental health diagnosis:Please specify genetic/chromosome abnormality:Please specify other:How often does your child have a bowel movement?DailyEvery other dayOtherDoes your child have issues with the following? Constipation (hard stools) Diarrhea (loose stools) Is your child allergic to or does he/she react to the following? If yes, please describe the reaction. Prescription medicines Reaction: Over-the-counter medicines, supplements, or herbal remedies Reaction: Foods, food additives, or drinks Reaction: Latex or anything such as bandages or tape Reaction: X-ray, CT, MRI, or other radiology dyes Reaction: Blood products Reaction: Eating EnvironmentWhere does your child usually sit during mealtimes? Infant seat Child stands On parent/caretaker’s lap Highchair Child wanders around Booster seat in front of TV Chair at table Held in parent/caretaker’s arms Other Please specify other:Where in the house is your child fed? Kitchen Dining room Living room Walking around Other Please specify other:With whom does your child usually eat/drink? Alone With parents With siblings With peers With nurse At what other locations does your child eat/drink? Daycare School Other relative's house In the car Other Please specify other: Eating and DrinkingWho feeds your child? Mother Father Sibling Grandparent Nurse Teacher/daycare provider Other Please specify other:Please note your child’s current feeding skills. Spoon fed Type of spoon: Child feeds self Finger feeding:BeginningPartially successfulCompletely successfulFeeds self with spoon:BeginningPartially successfulCompletely successfulFeeds self with fork:BeginningPartially successfulCompletely successful Drinking from breast When is breast offered? Drinking from a bottle Type of nipple: Regular Orthodontic Other Please specify other:How is your child positioned during feeding? Seated Held Other Please specify other:When is bottle offered? Drinking from a cup Type of cup: Drinking from a straw What does your child drink? Milk Infant formula Water Nutritional supplement Juice Soda/tea Other Milk: Ounces per day and type of milkFormula: Ounces per day and name of formulaWater: Ounces per dayNutritional supplement: Ounces per day and name of supplementJuice: Ounces per daySoda/tea: Ounces per dayPlease specify other: Food TexturesPlease select your child’s current ability to eat the following food textures.Baby foodEats EasilyEats with DifficultyRefusesCannot EatNever TriedPureed table foodEats EasilyEats with DifficultyRefusesCannot EatNever TriedMashed table foodEats EasilyEats with DifficultyRefusesCannot EatNever TriedDissolvables (e.g., puffs, veggie sticks, Cheerios)Eats EasilyEats with DifficultyRefusesCannot EatNever TriedChopped table foodEats EasilyEats with DifficultyRefusesCannot EatNever TriedSoft table food (e.g., pancakes)Eats EasilyEats with DifficultyRefusesCannot EatNever TriedCrunchy table food (e.g., apple, crackers)Eats EasilyEats with DifficultyRefusesCannot EatNever TriedDifficult-to-chew table food (e.g., meat)Eats EasilyEats with DifficultyRefusesCannot EatNever TriedPlease give examples of food your child will eat from all food groups. Fruits:Vegetables:Grains (breads/cereals/pasta/rice):Meats/eggs/peanut butter:Dairy (milk, cheese, yogurt): Diet AssessmentPlease 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 barBreakfastFood/Drink ItemAmount Child Actually Eats/Drinks Click (+) to add items.SnackFood/Drink ItemAmount Child Actually Eats/Drinks Click (+) to add items.LunchFood/Drink ItemAmount Child Actually Eats/Drinks Click (+) to add items.SnackFood/Drink ItemAmount Child Actually Eats/Drinks Click (+) to add items.DinnerFood/Drink ItemAmount Child Actually Eats/Drinks Click (+) to add items.Bedtime SnackFood/Drink ItemAmount Child Actually Eats/Drinks Click (+) to add items.