Feeding Therapy Questionnaire
Thank you for taking the time to take our questionnaire to see if feeding therapy is right for you!
1. Does your child have a restricted and repetitive diet, with refusal to try any new foods?
Yes
No
2. Does your child have difficulty letting you know when they are hungry and/or when they are full?
Yes
No
3. Are your child's preferred foods mostly made up of the same texture, colour and/or taste? (e.g. white and crunchy)
Yes
No
4. Does your child avoid being messy and/or show sensory challenges towards food?
Yes
No
5. Does your child become anxious around trying new foods?
Yes
No
6. Does your child require devices (iPad/TV) in order to eat and/or do they have difficulty remaining seated for the duration of a meal?
Yes
No
7. Do you feel that your child eats more or less than expected for their age?
Yes
No
8. Does your child have less than 20 'safe/preferred' foods?
Yes
No
9. Do your mealtimes typically last less than 5 minutes or more than 30 minutes?
Yes
No
10. Has the feeding challenge occurred for longer than 3 months?
Yes
No
11. Does your child require additional supplementation (e.g. NG/Peg Fed, formula, Pediasure etc)?
Yes
No
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First Name
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