Associated Feeding Problems
Estimate the frequency of occurrence for each of the following per day:
a. _____ Vomiting/rumination
b. _____ Teeth grinding
c. _____ Coughing
d. _____ Gagging
e. _____ profuse perspiration (diaphoresis)
Were any of the following used during the infancy period? (please circle)
Tracheotomy tube NG tube Nasal cannula Gastrostomy tube
Food Preference Inventory
• Circle about how often your child eats at least a portion of this food (the portion is listed after the food);
No = a portion of this food is never eaten
Week = at least once per week
Day = once per day
Many = more than once per day
• If the child eats other foods not included here, write them in the blanks below.
Food
How often is the food eaten by the child?
Is this food eaten by the Family?
FOOD |
How often child eats the food Please X the box |
Does family eat the food? |
Apples |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Apricots |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Avacado |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Banana |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Banana Chips |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Berries |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Cantelope |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Cherries |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Grapefruit |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Fruit Cocktail |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Grapes |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Honey Dew |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Kiwi |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Mango |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Nectarine |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Oranges |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Peaches |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Pears |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Pineapple |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Plums |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Prunes |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Strawberry |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Watermelon |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Beets |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Broccoli |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Cabbage |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Carrots |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Cauliflower |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Coleslaw |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Celery |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Corn |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Creamed Corn |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Cucumbers |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Peas |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Green/ Wax beans |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Lettuce/salad |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Lima beans |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
onions |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
green peppers |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Pickles |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Radish |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Asparagus |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Spinach |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Squash |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Sweet potato |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Tomato |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Turnip |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Potato(mashed/baked) |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Apple Sauce |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Apple Juice |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Cranberry sauce |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Cranberry Juice |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Grapefruit Juice |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Grape Juice |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Lemoade |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Orange Juice |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Prune Juice |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Milk |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Chocolate Milk |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Hot Chocolate |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Milkshake |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Rasins |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Crackers |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Fruit roll-ups/ snacks |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Other candy/ sweets |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Pie |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Potato Chips |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Pretzels |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Pudding |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Sherbert |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Ice Cream |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Tofu |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Cake (any kind) |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Cheese puffs/curls |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Chocolate candy |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Cookies |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Donut/ Pastry |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
French Fries |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Peanut Butter |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Peanuts |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Other nuts/seeds |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Popcorn |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Muffins/ Rolls |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
American Cheese |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Cheese Spread |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Eggs |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Cottage Cheese |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Cream Cheese |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Sour Cream |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Other Cheese(s) |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Yogurt |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Bagel |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Breakfast Bars |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Cereal(cold) |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Cornbread |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Cream of Wheat |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
French Toast |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Grits |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Oatmeal |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Pancakes |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Poptart |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Pita |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Rice |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Wheat/Grain bread |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
White bread |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Bacon |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Baked Beans |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Chicken |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Chicken Nuggets |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Chicken Salad |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Clams/Oysters |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Crab/Lobster |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Shrimp |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Fish |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Fish Sticks |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Ham |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Ham Salad |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Hamburger |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Hotdog |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Lamb |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Lentils |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Liver |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Lunchmeat |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Meatloaf |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Other Beans |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Corn/tortilla chips |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Taco/ Burrito |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Tuna Salad |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Turkey |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Veal |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Venison |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Chili |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Pot Pie |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Soup |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Stew |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Stuffing |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Egg Noodles |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Pork |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Roast Beef |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Sausage |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Steak |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Lasagna/ Ravioli |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Macaroni |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Noodles |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Ramen Noodles |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Pizza |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Potato Salad |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Spaghetti |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Spaghetti O's |
[ ]No [ ]Week [ ]Day [ ]Month |
[ ]YES [ ] NO |
Drinking Preference Inventory (circle or fill-in the blank; 1 cup = 8 ounces) Does your child drink a supplement (e.g. Pediasure, Boost, etc.)? Yes No If yes, which one?_________________________________ How much/ day?__________________ What kind of milk does your child usually drink? Whole 2% 1% Skim Soy Rice? How much/day? ___________
Is your child’s milk usually flavored? Yes No
If yes, what is used? Chocolate/strawberry syrup Flavored powder Instant Breakfast Ovaltine Other__________
Does your child drink? Hot chocolate Milkshake Drinkable yogurt How many ounces of these drinks does your child drink per day? _______ ounces How much 100% juice does your child drink per day? _______ ounces
How much other fruit drinks (Hi-C, Kool Aid, etc.) does your child drink per day? ______ounces How much soda or iced tea does your child drink per day? _______ ounces
Does it usually have caffeine? Yes No What type is it usually? Regular Diet
How much water does your child drink per day? _______ounces
What issues are you trying to resolve? (Check as many as apply)
Increase the volume of food my child eats Increase the texture of food my child eats Increase the variety of foods my child eats Improve cup drinking Improve oral motor skills Improve mealtime behaviors Decrease gagging during eating Decrease vomiting related to eating Reduce/eliminate diarrhea Reduce/eliminate constipation Increase weight gain Decrease tube feedings Resolve reflux or other GI issues Other
Was feeding interrupted at any time in the child's history? Yes No
a. For how long? ___________________________________________
b. For what reason? ________________________________________
Where does the child eat? (Check all that apply)
[ ] Caregivers Lap
[ ] Booster Seat
[ ] Infant Seat
[ ] Highchair
[ ] Chair at the table
[ ] Other
Does the child have any of these issues at mealtimes? (check all that apply)
[ ] Throws food during meal
[ ] Messy eater
[ ] Spits out food
[ ] Takes food from others
[ ] Cries or Screams at meal time
[ ] Refuses to self-feed
[ ] Leave the table before finished
[ ] Overeats
How many times in the last week did any of the following events occur?
Never 1-2 meals 3-4 meals 5+meals
How many meals did your child eat without an adult?
How many meals did your child eat with the T.V. on?
How often did you make your child a separate meal because he/she would not
eat the family meal?
How many meals eaten at home were with peers or siblings?
How often did your child request food other than at scheduled meal or snack
times?
How many meals did your child not eat at the kitchen or dining room table?
How many meals were eaten at “fast food” restaurants?
How often do the following typically occur?
Always Usually Sometimes Seldom Never
Do you allow your child to eat whenever they request food between
meals?
Do you make mealtimes fun or entertaining?
Do you insist your child try ‘one bite’ of a new food?
Do you insist your child take a bite of each food before they can
leave the table?
Do you physically put food into your child’s mouth?
Do you allow your child to choose favorite plates or utensils to eat
with?
Do you punish your child for not eating (spanking or time-out)?
Do you insist your child ‘clean his/her plate’ before they leave the
table?
Do you praise your child for eating?
Do you offer activities as a reward for eating?
Do you give your child the option of eating foods other than those
served?
Do you send your child away from the table if he/she is not eating?
Do you allow your child to flavor foods however he or she wants?
Do you make your child stay at the table until all or a certain amount
of food has been eaten?
Do you restrict your child from eating certain foods without your
permission?
Do you give your child dessert for eating certain foods?
Do you encourage your child to eat fruits and vegetables every
day?
Food Consistency: Please check all that are applicable:
Liquid/ Soup [ ] Does eat [ ] Can eat [ ] Never tried [ ] Cannot eat
Stage 1 or 2 baby food [ ] Does eat [ ] Can eat [ ] Never tried [ ] Cannot eat
Stage 3/ Junior baby food [ ] Does eat [ ] Can eat [ ] Never tried [ ] Cannot eat
Creamy foods [ ] Does eat [ ] Can eat [ ] Never tried [ ] Cannot eat
Blenderized table food [ ] Does eat [ ] Can eat [ ] Never tried [ ] Cannot eat
Mashed table food [ ] Does eat [ ] Can eat [ ] Never tried [ ] Cannot eat
Chopped table food [ ] Does eat [ ] Can eat [ ] Never tried [ ] Cannot eat
Regular table food [ ] Does eat [ ] Can eat [ ] Never tried [ ] Cannot eat
Crisp food (crackers) [ ] Does eat [ ] Can eat [ ] Never tried [ ] Cannot eat
Chewy food (meat) [ ] Does eat [ ] Can eat [ ] Never tried [ ] Cannot eat
Crunchy food (carrots) [ ] Does eat [ ] Can eat [ ] Never tried [ ] Cannot eat
Describe any special diet. __________________________________________________________
Meal Pattern
Please write down a 3-day diet history on the back of one of these pages or on another piece of paper. Include everything your child has to eat or drink, approximate amounts eaten, and what time they were eaten.
Describe a typical meal in detail (what happens when you offer food?)
Do the child's food habits and preferences match the family's? Yes/ No
Does the child eat little at meals and snack throughout the day? Yes/ No
Appetite is best described as: (circle one) poor fair good excellent eats too much
How long does it take for the child to complete a meal? (circle one)
less than 10 min. 10-20 min. 20-30 min. 30-60 min. over 60 minutes How does the child indicate hunger? _________________________________________
Does your child currently have, or has your child had, any of the following issues?
Check the appropriate box(es).
Autism [ ] Current [ ] Previous [ ] Non-applicable
PDD, or Asperger’s Gastroesophageal Reflux [ ] Current [ ] Previous [ ] Non-applicable
Developmental or Speech Delay [ ] Current [ ] Previous [ ] Non-applicable
Chronic Constipation [ ] Current [ ] Previous [ ] Non-applicable
ADHD [ ] Current [ ] Previous [ ] Non-applicable
Chronic Diarrhea [ ] Current [ ] Previous [ ] Non-applicable
Learning Disability [ ] Current [ ] Previous [ ] Non-applicable
Food Allergies [ ] Current [ ] Previous [ ] Non-applicable
Mental Retardation [ ] Current [ ] Previous [ ] Non-applicable
Lactose intolerance [ ] Current [ ] Previous [ ] Non-applicable
Traumatic Brain Injury [ ] Current [ ] Previous [ ] Non-applicable
Seasonal Allergies [ ] Current [ ] Previous [ ] Non-applicable
Depression or Bipolar Disorder [ ] Current [ ] Previous [ ] Non-applicable
Blind or Severe Vision Impairment [ ] Current [ ] Previous [ ] Non-applicable
Anxiety Disorder or OCD [ ] Current [ ] Previous [ ] Non-applicable
Deaf or severe hearing impairment [ ] Current [ ] Previous [ ] Non-applicable
Cerebral Palsy [ ] Current [ ] Previous [ ] Non-applicable
Delayed Gastric Emptying [ ] Current [ ] Previous [ ] Non-applicable
Spina Bifida [ ] Current [ ] Previous [ ] Non-applicable
G-tube or NG-tube Feeding [ ] Current [ ] Previous [ ] Non-applicable
Seizure Disorder [ ] Current [ ] Previous [ ] Non-applicable
Liver Disease [ ] Current [ ] Previous [ ] Non-applicable
Diabetes type I or type II [ ] Current [ ] Previous [ ] Non-applicable
Endocrine Disorder or Problems with Growth [ ] Current [ ] Previous [ ] Non-applicable
Prematurity [ ] Current [ ] Previous [ ] Non-applicable
Heart Problems [ ] Current [ ] Previous [ ] Non-applicable
Kidney Disease [ ] Current [ ] Previous [ ] Non-applicable
Asthma or Lung problems [ ] Current [ ] Previous [ ] Non-applicable
Any Other Medical Condition, Developmental Problem, or Behavioral Issue: ( List below)
Current Oral - Motor Status
Are there any problems or concerns with? (check all that apply)
[ ] Drooling
[ ] Poor sucking
[ ] Poor tongue control
[ ] Problems biting
[ ] Poor lip control
[ ] Lack of chewing
[ ] Swallowing problems
[ ] Hypersensitive to temperature, texture, etc.
[ ] Teeth grinding
[ ] Sweating while eating
[ ] Coughing/ gagging
[ ] Ruminating/ vomiting
Were any of the following ever used ? (Please circle)
Tracheotomy tube NG tube nasal cannula Gastrostomy tube
Current Tube Feeding Information
Type of feeding tube (please circle): G- tube J-Tube NG- tube NJ- tube Type of formula used: __________________
What is the caloric density (how many calories per ounce)? __________________ What does your child receive from the tube feeding in 24-hours (please specify formula, water, etc.)? How is feeding done?
Continuous feeding:
How much per hour_________ Time feeding run (start time/stop time)_______________ Bolus feeds:
What is the bolus schedule? __________________________________________ Volume per bolus____________________ How long does a bolus feed take? _____________
Fill in the appropriate answer:
1. How many times per week does your child vomit during or within one hour of tube feeding? 0 times 1-3 times / 4-6 times / 7-9 times / 10 or more times
2. How much does your child typically vomit? Less than one tablespoon / About one tablespoon / More than one ounce
3. How many times per week does your child gag or retch during or within one hour of tube feeding? 0 times 1-3 times / 4-6 times / 7-9 times / 10 or more times
4. How many times per week does your child cry during or within one hour of tube feeding? 0 times 1-3 times / 4-6 times / 7-9 times / 10 or more times
5. How many times per week does your child sleep through the night without awakening? 0 days 1-2 days / 4-5 days / 6-7 days
6. How often does your child experience problems with constipation? Daily / Weekly / Monthly ?
7. How often does your child experience problems with diarrhea? Daily / Weekly / Monthly ?
8. Have you had difficulty increasing the rate or volume of your child's tube feeding?
9. Has your child had difficulty gaining weight on the current tube feeding schedule?
Current Feeding Skills (check all that apply)
[ ] drinks from bottle [ ] held by caregiver [ ] child holds
[ ] feeds self with spoon [ ] with help [ ] without help
[ ] feeds self with fork [ ] with help [ ] without help
[ ] drinks from open cup/ glass [ ] with help [ ] without help
[ ] drinks from sippy/tippy cup [ ] with help [ ] without help
Please list:
1. Favorite food
2.Favorite recreational materials
3.Favorite activities
Please list any and all other concerns you have for your child’s eating/ feeding habits and or issues.