Gestation:   Number   Weeks   Number   Days
Birth Weight:   Number   LBS ,   Number   Ozs
Multiple Birth (twins/triplet):  Yes   No   
Type of Delivery:   Vaginal   C-Section 
Delivery Complications?      

NICU Duration:      Months      Days

Reflux/GERD   Yes   No   
Age of Diagnosis
Medications trialed List
Current medicationsList  
Does Reflux cause a gurgly voice or coughing   Yes   No       

Tracheostomy Tube?        Yes   No    
If yes:
Date of Decannulation:   Date   
Brand/Size:   List   
Reason for Placement: Describe
Date of Placement:   Date   
Complications (if any): blank
Date of most recent endoscopy:   Date   
Tolerance of speaking, valve/capping:   Yes   No    
Type and size of speaking valve:   Type a label   
Frequency of suctioning:   Type a label   
Viscosity/Color of secretions:   Type a label   

Currently on Oxygen:   Yes   No      
Oxygen use in the past:   Yes   No   
If yes to either:
Via:   Nasal Cannula   Trach Shield   
Frequency   Type a label   , Amount      %,
O2   Type a label Liter flow   Type a label   
Ventilator dependency:   No   Current    Previous   
Oral Suctioning     Yes   No   
Frequency of Oral Suctioning:   Type a label   

Cardiac History:   Yes   No   
If yes:
Type of problem:      
Related surgery:      
Episodes of cyanosis:    Yes   No  

Cranio-Facial History   Yes   No   
Type:Complete (hard, soft palete and lip)   Incomplete (Soft Palate only)   Incomplete (Lip only)   Sub mucus cleft   
Please indicate:   Left   Right      
Please indicate:   Bilateral   Unilateral   
Select any that apply     Retrognathia (small jaw)   Nasal Regurgitation (through nose)      Ear malformation   Dental abnormalities   

Alternate Feeding?   Yes   No
Type:     
G-tube    NG-tube    PEG tube    GJ tube   J-tube   TPN    
Site Care Routine:   Site Care    
Size:   Size   
Balloon:   Balloon   
Type:   Type   
Date of insert:   Date   
List any complications:    
Fundoplication:   Yes   No   
Related Surgeries:   Type a label   

Please answer if applicable
Bottle/Nipple used for feedingblanks
Formula/EBM:     
Oz consumed per bottle:   Number oz
Length of avg. bottle time:   < than 5 mins   5-20 mins   20+ mins     
Who is the primary feeder (mom, dad, other)       
Primary position     Supine   Side Lying   Elevated   Cradle
Food temperature preference   Warmed   Chilled   Variable    
Daily Volume in ounces      oz
Modifications to feed   Type a label   

Typical time (in minutes) spent breastfeeding on each breast
Left   Number   Right   Number   
Nipple Shield:   Yes   No   
Milk Production:   Exessive, more than child needed   Average      Low, not enough to meet childs needs 
Feeding time   Scheduled   On Demand      
Childs response to feeding   VigorousLethargic Fussy  Comfortable   Variable
Select all that apply:   Child frequently spits up   Child frequently vomits   Child shows extreme discomfort during or after feeding   

List the following ages (in months) when the child did the following:
Walked alone:   Months   
Spoke first word:   Months   
Used 2 word phrases:   Months   
Understood and followed simple instructions:   Months   
Toilet trained:   Months   

Childs temperament as infant:   Cried Excessively   Never Cried   Generally Happy