Feeding Form - CC Therapy
check off foods that your child currently eats. If your child accepted a food item in the past but no longer eats the food please write that in the notes section under the heading. This form allows the team to be able to establish a starting point, assess progress and strategically advance your child's food inventory.
Child's Name
First Name
Last Name
Name of Person Completing The Form
First Name
Last Name
Texture Preferences
Crunchy
Crisp
Smooth
Lumpy
Uniform Lumpy (cottage cheese)
Hard
Chewy
Mixed Consistencies
Texture Preferences - Notes
Taste Preferences
Salty
Sweet
Spicy
Tart
Flavored
Bland
Taste Preferences Notes
Temperature Preferences:
Hot
Warm
Cold
Cool
Temperature Preference Notes:
Best Time of Day to Eat
Overall Description of Appetite
poor
fair
good
varies day to day
Selective Eating Age of Onset (if known) - when did this start?
Current # of Accepted Foods:
Current # of Accepted Liquids:
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Breads
Check the Boxes of Items Your Child is Eating
crackers
chips
pretzels
snack mix
cheese puffs
bugles
tostitos/taco chips
Taco Shells (hard)
flour tortillas
rolls
pizza crusts
hamburger or hot dog buns
bread (white, wheat, rye, potato etc.)
garlic bread sticks
texas toast/garlic bread
hot rolls, baked bread, crescent rolls, croissants
biscuits
doughnuts, sweet rolls, cinnamon rolls, caramel rolls
banana bread, pumpkin bread, apple bread, muffins
corn bread
cupcakes
cake, pies, pastries
cheesecake
cookies
Notes
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Meats
Check the Boxes of Items Your Child is Eating
Baked Chicken
Fried Chicken
Chicken Strips
Chicken Nuggets
Turkey
Poultry
Fish (Fried)
Fish (baked/broiled)
Tuna
Salmon
Beef (steak, roast, deli style)
Roast
Ribs
Deer
Hamburger
Steak
Ham
Veal
Pork
Sausage
Bacon
Chicken or Ham Salad
Tuna Salad
Meatballs
Hot Dogs
Corn Dogs
Bologna
Lunch Meat
Lil' Smokies
Baby Food Meat Sticks
Baby Food Meats
Notes:
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Nuts
Check the Boxes of Items Your Child is Eating
Peanut Butter
Peanuts
Walnuts
Cashews
Pecans
Notes:
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Potato Products
Check the Boxes of Items Your Child is Eating
french fries
tator tots
tater rounds
hash browns
fried potatoes
baked potatoes
potato chips
potato wedges
shoestring potato sticks
mashed potatoes
mashed potatoes with butted
mashed potatoes with gravy
scalloped/au gratin potatoes
baked sweet potatoes
candied sweet potatoes
sweet potato chips
sweet potato fries
vegetable chips
Notes:
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Condiments
Check the Boxes of Items Your Child is Eating
ketchup
mayo
miracle whip
mustard
dijon mustard or spicy mustard
honey mustard
BBQ
chikfila sauce
A1 steak sauce
ranch
worcestershire sauce
thousand island dressing
french dressing
Vinaigrette
butter or margarine
chip dip
gravy
Notes:
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Breakfast Foods
Check the Boxes of Items Your Child is Eating
oatmeal
cream of wheat
pop tarts (frosted or plain)
dry cereal
cereal with milk
pancakes
pancakes with fruit
pancakes with syrup
waffles (homemade)
waffles (frozen)
french toast
scrambled eggs
omelet eggs
fried eggs
boiled eggs
poached eggs
cheese on eggs?
veggies in eggs?
salsa in eggs?
chopped meats in eggs?
Toast plain
toast with cinnamon and butter
toast with jelly
toast with peanut butter
toast with apple butter
toast with honey (after age 2)
breakfast shake
yogurt
go gurt
fresh fruit
grits
Notes:
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Vegetables
Check the Boxes of Items Your Child is Eating
green beans
brocolli
cauliflower
corn
squash
cucumber
zucchini
spinach
carrots
lettuce
coleslaw
cabbage
sweet potatoes
tomatoes
asparagus
brussel sprouts
green pepper
onion
peas
salsa
baby veggie food
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Liquids
Check the Boxes of Items Your Child is Eating
juice (describe in the notes which kinds)
lemonade
milk
flavored milk
water
soda
tea
milkshake
float
drinkable yogurt
caloric supplements (describe in notes)
Notes:
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Fruits
Check the Boxes of Items Your Child is Eating
apple
banana
blueberry
cantaloupe
cherry
grapes
kiwi
lemon
lime
orange
pear
pumpkin
watermelon
raisin
raspberry
rhubarb
strawberry
tangerine
tomato
dried fruit
Notes:
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Pasta/Italian
Check the Boxes of Items Your Child is Eating
spaghetti
lasagna
spaghetti o's
spaghetti o's + meatballs
ravioli
tortellini
casseroles (hamburger helper)
Pizza (include accepted toppings in the notes section)
rice
mac n cheese
Notes:
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Soups
Check the Boxes of Items Your Child is Eating
cheese
cheese and broccoli
cheese and veggies
chili
stew
vegetable
vegetable and beef
french onion
egg drop
beef noodle
chicken noodle
chicken and rice
pea
Notes:
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Cheese/Dairy
Check the Boxes of Items Your Child is Eating
cheddar
american
parmesan
swiss
monterey Jack
Mozzarella
colby
cottage cheese
sour cream
yogurt
cool whip
whipped cream
ice cream
sherbet
Notes:
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Open Ended Questions
Fast Foods Your Child Likes (name of location + food items)
List Your Child's Favorite Foods/Liquids
List Your Child's Least Favorite Foods/Liquids
What Goal Foods Would You Like to See Your Child Eat With The Rest Of The Family?
Are There Times When Your Child Eats Well
Is Your Child Taking Any Medications?
Describe Meal Time (where your child is sitting, environment, etc)
Is Your Child Involved in Food Preparation?
What Cups/Bottles Are You Using Currently?
Have You been seen by a GI, Nutritionist or Feeding Specialist Prior to completing this intake form? If Yes, Describe
Comments re: Feeding or Specific Foods That May Be Helpful To Know
Thank you for Completing This Form
By being so thorough this will not only help us as a team but help you in learning more about your child, their patterns and how to support them to have an increased quality of life with their meal time and family time.
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