Feeding Intake Step 1 of 3 33% Parent or Guardian First Name* Parent or Guardian Last Name* Phone Number*Email Address* Street Address* City* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP Code* Date MM slash DD slash YYYY Identifying and Education InformationChild's Name* Date of Birth* MM slash DD slash YYYY Age* Gender* Male Female Weight* Height* Referring Physician and Practice* Primary Diagnosis Reason for Referral* Pediatrician and Practice* Phone Number*Other Specialists (e.g., GI, Allergist, Dietician) Phone NumberWho is filling out this form?* Relationship to Child* How did you hear about the EBS Feeding Program?* Languages Spoken at Home* Is your child enrolled in any type of childcare facility or school?* Yes No Name of School/Facility Date Enrolled MM slash DD slash YYYY Hours Per Week Current Grade Describe any special assistance or accommodations provided in the educational setting.Has your child ever had a Feeding/Speech and Language/Occupational/Physical/Behavioral/Psychological evaluation?* Yes No Select the type of evaluation he/she has had. Feeding Speech and Language Occupational Physical Behavioral Psychological Date of Evaluation Would you share the results with us? Yes No Does your child receive therapy at this time?* Yes No Number of Sessions Per Week Where does your child receive these services? Has your child received therapy services in the past?* Yes No Type of Therapy and Date Services Ended Past and Current Medical InformationPrenatal/Birth History Please fill out this section to the best of your ability, with as much detail as possible. Length of Pregnancy (weeks)* Were there any complications during pregnancy or delivery?* Yes No If yes, please explain.Type of Delivery* Vaginal Cesarean Section Hospitalization/Surgical History Has your child ever been hospitalized or had surgery?* Yes No Date(s) of Hospitalization/Surgery Reason(s) for Hospitalization/Surgery Diagnostic History Does your child have any current or past diagnoses?* Developmental Milestones At approximately what age did your child begin to:Roll over* Sit unaided* Crawl* Stand unsupported* Walk* Length of time between crawling and walking:* Sleep through the night* Babble* Use words* Combine words* Use sentences* Did your child enjoy tummy time or prefer to play in other positions?* Known Precautions/Allergies Medical Allergies* None Latex Other If "Other," please explain. Food Allergies* None Dairy Gluten Nuts Soy Other If "Other," please explain. Does your child require an EpiPen for any allergies?* Yes No Food Intolerances* None Dairy Gluten Nuts Soy Other If "Other," please explain. Does your child have any other dietary restrictions? Current Medications Does your child take any medications?* Yes No Please list all medications including dosage, how long child has been taking, and reason for prescription. Neurologic History/Current Concerns Does your child have a history of neurologic deficits?* Yes No Select neurologic deficit(s). Abnormal Muscular Tone (high) Abnormal Muscular Tone (low) Anoxia Ataxia Brain Tumor Hydrocephalus Microcephaly Paralysis Seizures Stroke TIAs Tremor Other If any box checked, please explain.Current Neurologic Status:* No problems Current issue(s) Regular follow-up with neurologist If current issues, please explain. Cardiac History/Current Concerns Does your child have a history of heart problems?* Yes No If yes, please indicate the specific heart problem or suspected problem. Please check if any of the following have occurred. Surgery Episodes of cyanosis Altered activity level Intolerance of specific positions secondary to cardiac condition Known complications from cardiac condition: CVAs TIAs Vocal fold paralysis Other If any box checked, please explain.Current Cardiac Status: No problems Current issue(s) Regular follow-up with cardiologist If current issues, please explain.Physician's Name Respiratory History/Current Respiratory Concerns Does your child have a history of respiratory problems?* Yes No Check all respiratory issues that apply. Apnea (Obstructive) Apnea (Central) Asthma Bronchitis/Bronchiolitis Bronchopulmonary Dysplasia (BPD) Malacia (Broncho) Malacia (Laryngo) Malacia (Tracheo) Nasal/Chest Congestion Pneumonia Tracheal Stenosis Wheezing Other If pneumonia, how many times? Was it ever classified as aspiration pneumonia? Yes No If yes, please explain. Approximate number of colds per year: Normal Above average Approximate number of upper respiratory infections per year: Does your child have a tracheostomy tube? Yes No If yes, reason for trach AND length of time child had the trach:Please explain any complications related to the trach (granuloma tissue build-up, etc.). Gastrointestinal History/Current Gastrointestinal (GI) Concerns Does your child have a history of GI problems/concerns?* Yes No If yes, check all that apply. Altered Peristalsis Bowel Obstruction Crohn’s Disease Chronic Diarrhea Constipation Dehydration Diabetes Esophagitis (Eosinophilic) Esophagitis (general) Failure to Thrive GI Bleeding Hypoglycemia Reflux Slow Gastric Emptying Short Bowel Syndrome Vomiting Other If any box checked, please explain.History of GI surgery? Yes No If yes, check all that apply. Colostomy Fundoplication Pyloromyotomy Short gut Did your child ever receive any alternative feeds? Yes No If yes, please select all that apply. G-Tube J-Tube NG Tube PEG Tube PEJ Tube TPN Other If "Other," please explain. Type of feeding received: Bolus Continuous Drip Combination Has your child ever had any of the following tests completed? MBS FEES Study Upper GI Barium Swallow pH Probe Sialogram Other If "Other," please explain. Please indicate the dates and results of tests. If multiple tests completed, only provide the most recent.When was baby cereal introduced? What type? Current GI status (check all that apply): No problems Current issue(s) Regular follow-up with gastroenterology Physician’s Name Regular follow-up with pediatrician for GI issues? Yes No Do you or your child's doctor have concerns about recent weight gain or weight loss? Yes No If yes, please explain.Has your child ever had a nutritional consult? Yes No If yes, please provide the name of consultant and date last visited with any pertinent comments.Has your child ever had a blood test to determine nutritional deficits? Yes No If yes, please provide date of most recent testing and results.Does your child currently have reflux? Yes No If applicable, when did the reflux resolve? Who said it was resolved? If yes, have you ever noted coughing or a “gurgly” voice after the episode? Yes No Does your child currently suffer from recurrent vomiting? Yes No If yes, approximately how many times daily does he/she vomit? Is your child currently receiving tube feeds? Yes No If yes, check all that apply. G-Tube J-Tube NG Tube PEG Tube PEJ Tube Other If "Other," please specify. Current Rate: Current Schedule: If any additional current GI issues, please explain. Craniofacial History/Current Craniofacial Concerns Does your child have any past or current craniofacial concerns?* Yes No If yes, please describe. Dental History/Current Dental Concerns History Has your child ever been to the dentist?* Yes No Most recent dental visit and results:Has your child ever had dental surgery or any unusual dental findings?* Yes No If yes, please explain.Current dental status (check all that apply):* No problems Current issue(s) Regular follow-up with dentist/orthodontist Please explain.Does your child have a regular follow-up with dentist/orthodontist?* Yes No Does your child have normal dentition (number/placement of the teeth)?* Yes No If no, please explain.Are your child’s teeth currently brushed daily?* Yes No By whom?* Child Parent/Caregiver Reaction to tooth brushing:* Enjoys Resists If “resists” or “other,” please explain. Before leaving medical history, are any additional medical specialists involved with child? (Check all that apply.) Dermatology Psychiatry Psychology Other If any box checked, please explain. Current Nutritional Status/Feeding History/Responses to Food/Current SkillsCurrent oral feeds volume:* Exclusive (all nutrition received by mouth) Partial supplementation with tube “Tastes” (for pleasure/stimulation/exposure) N/A Early oral feeding trials: Chronology of formulas (if child less than 3, please indicate all formulas used and approximate month each formula began) and comments on tolerance:* For LIQUIDS, please answer the following questions: Does your child require the liquids to be thickened?* Yes No If yes, please indicate degree liquids are thickened (1 - slightly thick, 2 - mildly thick, etc.). Please indicate the length of time your child has been on thickened liquids. Please answer the following questions to the best of your ability. (If not applicable, enter "N/A.") Age child first took breast:* Takes breast now?* Yes No If no, age stopped: Age child first took bottle:* Takes bottle now?* Yes No If no, age stopped: Age child first used no-spill cup:* Uses no-spill cup now?* Yes No If no, age stopped: Age child first used straw:* Uses straw now?* Yes No If no, age stopped:* Age child first used open cup:* Uses open cup now?* Yes No If no, age stopped: Any additional objects child uses for taking liquids: How many ounces of fluid does your child consume daily?* Does your child ever cough or choke with liquids?* Yes No Does your child ever sound "gurgly" while drinking or immediately after?* Yes No If yes, please explain. Please select the types of liquid that are regularly consumed.* Water Breast milk Formula Milk Juice Soda Yogurt drinks Other If "Other," please specify. Comment on any preferences of a specific brand of nipple or cup.* Has your child at any time been breastfed?* Yes No Please describe the breastfeeding experience. For FOODS, please answer the following questions to the best of your ability. (If not applicable, enter "N/A.") Age child first took food from spoon (by caregiver):* Takes food from spoon now?* Yes No Comment: Age child first took food from caregiver's fingers:* Takes food from caregiver's fingers now?* Yes No Comment: Age child first used utensils by him/herself:* Uses utensils by him/herself now?* Yes No Comment: Age child first used fingers to feed self:* Uses fingers to feed self now?* Yes No Comment: Any additional methods in which child receives food: Approximately how many ounces of food does your child orally consume daily?* Does your child ever cough or choke with food?* Yes No Does your child ever sound "gurgly" while eating or immediately after?* Yes No If yes, please comment. Please select the types of food consistency that is regularly consumed.* Thin puree (e.g., baby-food apricots) Puree (e.g., pudding) Dissolvable solids (e.g., puffs) Soft solids (e.g., cheese, raisins) Hard solids (e.g., cookies, dry cereal) Multiple consistencies (e.g., dry cereal with milk) Difficult-to-chew foods (e.g., meat, raw vegetables) Other If "Other," please specify. Does your child require any specialized feeding equipment?* Yes No If yes, please comment. Please select the variety of foods that your child will eat. Fruits:* None 1–2 3–4 5 or more Comment: Vegetables:* None 1–2 3–4 5 or more Comment: Grains:* None 1–2 3–4 5 or more Comment: Dairy:* None 1–2 3–4 5 or more Comment: Meats:* None 1–2 3–4 5 or more Do you or your doctor have any concerns regarding the variety of foods that your child will eat?* Yes No If yes, please comment. Would you consider your child to be a “picky” eater?* Yes No Does your child prefer foods that are:* Room Temperature Hot Cold No Preference Smell and Sensitivities Child's sense of smell:* Typical Unknown Heightened Diminished Child's sense of taste:* Typical Unknown Heightened Diminished Child's taste preference:* Sweet Bitter Strong Sour Salty Would you say that your child gags easily with different foods?* Yes No If yes, please explain. Do you prepare special meals?* Yes No If yes, how many meals per day? Do you feel you to have play games to distract your child to get them to eat?* Yes No If yes, how frequently do you have to use this distraction? Do you feel you must reward the child to get them to eat? (i.e. airplane game, clapping, bubbles)* Yes No If yes, how frequently are the rewards used? Do you notice a difference in how much your child eats or how long they stay engaged based on who may be feeding them or different environments?* Yes No If yes, please explain. Does your child display any behavior problems during mealtimes?* Yes No If yes, please specify. Throws food Spits food Cries, screams Pushes food/plate away Takes food from others Overeats Leaves the table before finished Verbally refuses food Sneaks food Where does the child sit for mealtimes?* What type of chair does your child sit in?* If "Other," please specify. Who is typically present during meals?* Is there a time of day when meals are less challenging?* Does your child have any other behavioral issues outside of feeding? If so, please describe.* Strategies currently used for challenging behaviors AFTER they occur (please indicate what has been successful/unsuccessful):*Strategies currently used for challenging behaviors BEFORE they occur (please indicate what has been successful/unsuccessful):*Child’s preferred items/activities:* Does your child currently have a Positive Behavior Support Plan or Behavior Intervention Plan?* Yes No If so, will you share it with us?