Feeding Form
Child's Name
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First Name
Last Name
Food Allergies
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Yes
No
If Yes, Please List
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Please list who currently lives in the home
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Feeding Comments ( i.e. picky eater, swallowing difficulties etc.)
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What are your main concerns regarding feeding?
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Feeding
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Breastfed
Formula Fed
Combination
Please describe your child's initial skill on the breast and/or bottle
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During these early feedings, did your child frequently arch, cry, spit up, gag, cough, vomit or pull off the nipple? Circle the behaviors shown and describe when they would happen, and why, and for how long.
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At what age was your child introduced to baby cereal?
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Baby food?
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Finger foods?
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Table food?
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When did they fully transition to table food?
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Please list proteins that your child currently eats including specific brands if applicable.
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Please list starches that your child currently eats including specific brands if applicable (i.e. instead of 'crackers' please state which ones-cheez its, goldfish, ritz crackers, etc.)
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Please list vegetables that your child currently eats (indicate raw or cooked)
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Please list fruits that your child currently eats.
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Please list any foods that your child has eaten in the past, but refuses to eat now.
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Describe your child's mealtime
Who typically feeds your child?
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Who typically eats with your child?
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What type of chair is used?
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How long are meals typically?
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Does your child use utensils or any type of special cups/bowls? Please describe.
Are there any other activities going on at meals? What activities?
At what times does your child typically eat during the day?
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What does your child typically eat for breakfast?
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What does your child typically eat for snacks?
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What does your child typically eat for lunch?
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What does your child typically eat for dinner?
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Do you often have to cook a separate meal for your child?
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Yes
No
How does your child respond to new foods being offered to them?
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Has your child ever been on any type of special diet? If yes, please describe type of diet, at what ages, why and what was your child's response?
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Has your child lost or gained any weight in the last 6 months, and how much?
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Would you describe your child's weight as:
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Ideal
Underweight
Overweight
Does your child take a vitamin supplement? If so, which one?
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Does your child have/had any of the following problems (circle which ones)? Please describe: dental, frequent constipation, frequent diarrhea, vomiting, choking, gagging, coughing, etc.
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Have you noticed any difficulties with certain textures, smells, sounds, the way something looks, etc. Please explain.
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What have I not asked about that you would like me to know?
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Submit
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