Feeding History

Child's Name

First NameLast Name

Date of Birth

Please describe your child’s current feeding problem:

Breastfeeding and Bottle feeding

	From	To	Please describe
Breastfed
Bottle fed

During those early feedings, did your child frequently arch, cry, spit up, gag, cough, vomit or pull off the nipple? Describe when they would happen, why, and for how long:

	Yes/No	Describe	For How long?
Arch
Cry
Spit up
Gag
Cough
Vomit
Pull off the nipple
Bite

Describe the weaning process off the breast and/or bottle and why the child was weaned:

At what age was your child introduced to:

	Months	Comment
Baby cereal
Baby food
Finger foods
Solids
Transition to table food

Please describe how these transitions were handled by your child. Describe any difficulties in detail:

IF YOUR CHILD EATS BY MOUTH, PLEASE ANSWER THE FOLLOWING QUESTIONS:

Does your child...

	Often	Sometimes	Rarely
Need assistance to feed him/herself?
Tend to eat in a sloppy manner?
Frequently spill liquids?
Drool?
Have trouble chewing?
Have trouble swallowing?
Have difficulty eating foods with lumps?
Stuff or put too much food in his/her mouth?

List the carbohydrates that your child currently eats:

	Item	Favorite? (Check if yes)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

List the proteins that your child currently eats:

	Item	Favorite? (Check if yes)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

List the fruits that your child currently eats:

	Item	Favorite? (Check if yes)
1
2
3
4
5
6
7
8
9
10

List the vegetables that your child currently eats:

	Item	Favorite? (Check if yes)
1
2
3
4
5
6
7
8
9
10

List the drinks that your child currently enjoys:

	Item	Favorite? (Check if yes)
1
2
3
4
5
6
7
8
9
10

List the foods your child used to eat but no longer does

	Item
1
2
3
4
5
6
7
8
9
10

List the foods your child refuses:

	Item	Food or Drink?	History
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

List the foods your child is allergic to:

	Item
1
2
3
4
5
6

Describe your child’s mealtime:

Who typically feeds your child?
Who typically eats with your child?
What type of chair is used?
Are child's feet supported?
How long do meals typically last?

Does your child use eating utensils or any type of special cups/bowls (describe)?

Are there any other activities going on during meals (e.g. TV, hearing a story, conversation)? Please describe:

What time does your child typically eat and what kind of food (bottle, breast, solids)?

	Time of day	Drink	Solids (baby food, table)
1
2
3
4
5
6
7
8
9
10

Has your child ever been on any type of special diet other than what you just described?

YesNo

If yes, please describe the type of diet, at what ages, why and your child’s response:

How do you know your child is hungry?

How do you know your child is full?

Would you describe your child’s weight as: Ideal Underweight Overweight

Select any problems that your child has encountered: Dental Frequent constipation Frequent diarrhea Vomiting Choking Gagging Coughing Refuses to eat in school Refuses to eat outside the house

Describe problems encountered above:

Does your child take a vitamin supplement? Which one?

Describe how you feel after feeding your child:

Describe how your child feels after eating:

What other evaluations have been completed regarding your child’s feeding difficulties and what were the results?

What treatments have been tried for this problem and what were the results?

How can we be most helpful to you and your child?