Feeding Questionnaire

Feeding Questionnaire
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Parent Email
example@example.com
I. General Information
Primary reason for referral (check all that apply)

My child is feeding tube dependent and accepts little food by mouthMy child mostly get nutrition by drinking formulaMy child has lost weightMy child only eats certain food/ is extremely pickyMy child has poor self-feeding skillsMy child eats too much or is gaining weightOther
Describe what concerns you have about your child’s eating:
When did you first notice this problem?
II. Medical Information
Current Height
Current Weight
Has a medical provider ever expressed concerns regarding your child’s weight and growth?

YESNO
If yes, explain:
During infancy, how was child fed?

TubeBreastBottleCombinationOther
Was feeding ever interrupted any time in child's history

yesno
If yes, please explain:
Has your child had any of the following medical tests?

Swallow StudyEndoscopyGastric Emptying StudyAllergy TestingNone of the above
Please list any medical conditions your child has been diagnosed with. If your child has no known diagnoses, please mark N/A.
Frequency of bowel movements (by day or by week):
Consistency:

HardSoftLooseWatery
Is your child toilet trained:

YESNO
Are there any concerns with toileting? YES NO
If yes, what?
III. Feeding Skills
Is your child currently allowed to eat by mouth? YES NO
Is your child currently allowed to drink by mouth? YES NO
Indicate the age at which the following were introduced:
Solids:
Finger feeds:
Cup with spout:
Straw drinking:
Spoon:
Fork:
Open Cup drinking:
Knife:
Any difficulties noted with the above:
Current feeding skills (check all that apply)

drinks from bottleheld by caregiverchild holds bottlefeeds self with fingerswith helpwithout helpfeeds self with spoonwith helpwithout helpfeeds self with forkwith helpwithout helpdrinks from open cupwith helpwithout help
Any special diet that you adhere to for your child (i.e., gluten free, dairy free, kosher)
Please list any food allergies:
Please indicate your child’s typical mealtime schedule and sample meals. Give approximate amounts.

BREAKFAST
Sample/Typical Meal:
Amount Offered:
Amount Actually Eaten:
AM SNACK
Sample/Typical Meal:
Amount Offered:
Amount Actually Eaten:
LUNCH
Sample/Typical Meal:
Amount Offered:
Amount Actually Eaten:
PM SNACK
Sample/Typical Meal:
Amount Offered:
Amount Actually Eaten:
DINNER
Sample/Typical Meal:
Amount Offered:
Amount Actually Eaten:
Describe the sequence in which food is offered to your child (e.g., liquids always first, etc.):
Does your child’s food habits and preferences match the family’s? YES    NO Does your child eat little meals and snacks throughout the day? YES    NO
Your child’s appetite is best described as: Poor    Fair    Good    Excellent
How long does it take for your child to complete a meal? less than 10 minutes    10-20 minutes    20-30 minutes    over 30 minutes
Response to Feeding:

Arches backChokingCoughingCryingDifficulty chewingDroolingEats too fastEats too slowFails to chew food/swallows foods wholeGaggingLeaves the table before finishedHiccupingHolding food in mouthNasal regurgitationPockets food in cheekRefluxRefuses to open mouthSpillage of food/liquidSpits out foodStuffs mouthThrowing foodTurning head awayVomitingWet vocal quality after eating/drinkingWalks around/refuses to sit for meal
How does your child show hunger or thirst:
Do any foods cause physical problems when eaten? If yes, explain:
Indicate the age at which the following foods were begun:
Stage 1 baby food:
Stage 2 baby food:
Stage 3 baby food:
Table foods:
Difficulties noted with any of the above:
Please check (√ ) your child’s current ability to eat a variety of food textures:
Baby Food:

Eats EasilyEats with DifficultyRefusesCannot EatNever Tried
Pureed table food:

Eats EasilyEats with DifficultyRefusesCannot EatNever Tried
Mashed table food:

Eats EasilyEats with DifficultyRefusesCannot EatNever Tried
Dissolvables (e.g. puffs, veggie sticks,cheerios):

Eats EasilyEats with DifficultyRefusesCannot EatNever Tried
Chopped table food:

Eats EasilyEats with DifficultyRefusesCannot EatNever Tried
Soft table food (e.g. pancakes):

Eats EasilyEats with DifficultyRefusesCannot EatNever Tried
Crunchy table food (e.g. crackers, apple):

Eats EasilyEats with DifficultyRefusesCannot EatNever Tried
Difficult to chew table food (e.g. meat):

Eats EasilyEats with DifficultyRefusesCannot EatNever Tried
Sensory Preferences:

SweetSourBitterBlandSaltySpicySmooth pureesChunky pureesSoft solidsHard solidsHot foodsWarm foodsRoom temp foodsCold FoodsOther
Please give examples of food your child will eat from all food groups:
Fruits
Vegetables
Protein (meat/eggs)
Dairy (milk, cheese, yogurt)
Grains (bread, cereal, pasta, rice)
I have tried the following strategies when my child has a problem at mealtimes:

distraction during meals (e.g. games, TV)rewards/punishmentsfeeding child when s/he requests foodcoaxingpreferred foodsforcing foodshigh calorie supplements/formula
Check any of the following problems that occur for your child:

Drooling Poor suckingTongue Control (tongue thrust, poor mobility)Lip Control (keeping mouth closed)SwallowingPocketing food (holding food in cheeks/mouth)Chewing (for children over 1 year)Overstuffing (too much in mouth at one time)Hypersensitivity to textures, temperatures, spoonTeeth grindingAspirationCoughingOther
Tube Feeding

Please complete this section if your child requires supplemental tube feeding; if not applicable, please skip to next section.
When and why was a feeding tube placed?
Type of feeding tube
Which physician follows your child for tube feeding care?
What formula do you feed?
Where does tube feeding occur?
What is your child's tube feeding schedule (please list time, amount, rate, water flushes)
Does your child have difficulty tolerating tube feeding?
Childcare/Daycare Information
My child:

Attends school/daycareDoes not attend school/daycareChildcare is provided in home with a nanny/sitter
Name of school/Daycare
Has your school/daycare had concerns or been involved with addressing feeding/mealtime issues?
What meals does your child eat at school?
Do you feel your child gets adequate support for meals in the school/daycare setting?
Additional Parent Comments
Please include any other details that may be related to your child's feeding challenges.
Should be Empty:

Feeding Questionnaire

I. General Information

II. Medical Information

III. Feeding Skills

Tube Feeding

Childcare/Daycare Information

Additional Parent Comments