Feeding History Form Age 2 Under 2

Pediatric Feeding History Form
Patient Name
DOB
Please explain, in your own words, what you child's current feeding problem is.
Was your child breast fed?
From when to when?
Was your child bottle fed?
From when to when?
Please describe your child's initial skill with the breast and/or bottle:
During these early feedings, did you child frequently cry, arch, spit up, gag, cough, vomit or pull away? Circle behaviors, describe when they happened, why do you think and for how long?

Describe the weaning process off the breast and/or bottle, why weaned, how it went:
Check all that apply during your child's early feeding stages.

CryArchSpit upGagCoughVomitPull away
Describe when theses behaviors happened. Why do you think and for how long?
Describe the weaning off the breast and/or bottle process, why weaned, and how it went?
What age was your child introduced to: Baby cereal
Baby food
Finger foods
Table foods
When did they fully transition to table food?

Therapy Associates, Inc.
Please describe how these transitions were handled by your child, especially if any difficulties happened:
IF YOUR CHILD EASTS BY MOUTH, PLEASE ANSWER THE FOLLOWING QUESTIONS:
List the foods that your child currently will eat and drink (put a star next to their favorites):
List the foods your child refuses:
List the foods your child is allergic to:
Describe your child's mealtime:
Who typically feeds your child?
Who typically eats with your child?
What type of chair is used?
How long are meals typically?
Does your child use utensils or any type of special cups/bowls (describe)?
Are there any other activities going on at meals? What activities (describe)?

What times does your child typically eat and what type (bottle, breast, solids)

IF YOUR CHILD IS TUBE FED, PLEASE ANSWER THE FOLLOWING QUESTIONS
What type of formula is used and exactly how do you mix is?
Describe where your child is tube fed and what activities are occurring at the same time:
Describe your child's reactions to the tube feedings (connecting, during, disconnecting):

	Time of feeding (start time)	NG, G, or Continuous	Amount	Gravity or Pump	Over what time period or what rate

Pediatric Feeding History Form