Happy Eater's Intake Form

Parent Information
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
Time Zone*
Best Time to Contact
Phone Number*
Please enter a valid phone number.
Father's Height*
Mother's Height*
Child Information
Child's Name*

First NameLast Name
Child's Gender*

MaleFemale
Child's Date of Birth*

MMDDYYYY
Child's Weight at Birth*
Child's Current Height*
Child's Current Weight*
Current medications:
Current known allergies:
What medical conditions, if any, was your child diagnosed with?*
Feeding History
How was your child fed at birth?*
What was the first sign of eating issues?*
Oral Eating
Has your child been assessed for a safe swallow?*

YesNo
If yes, what study was performed?
When was it performed?
What where the results?
Give us a snapshot of your child’s swallow. Please include any observations made by a member of your medical team (feeding therapist, dr, etc).
Has your child ever been tube fed?*

YesNo
If formerly tube fed, when did your child wean from the tube?
Do you use rewards, distractions to encourage eating?
What are your child’s favorite foods or drinks?
Is there a texture your child prefers?
Is there a texture your child does not like?
How does your child eat?

BottleFingersSpoon (self-fed)Fed by someone
How does your child act around the food?

Leans into itCriesTurns awayOther (please describe)
Other
Do you feel you know what your child’s “yes”, “no”, “more”, cues are around feeding?
What is your mood around mealtime?
Therapy Experience (if any)
Has your child received any feeding therapy?

YesNo
If yes, please select which one:

OTPTSLPOther
What did you find most helpful?
What did you find least helpful?
Is your child receiving any developmental therapy? If so, what is it targeting?*
Give us a snapshot of your child's overall development in this moment.*
Has anyone ever told you your child may be on the autism spectrum? If so, please provide specifics.*
Has anyone told you your child might have sensory processing disorder? If so, please provide specifics.*
Family Impact
What do you hope for your child at this time?*
What do you hope to learn from this consultation program?
Is there anything else we need to know?
How did you hear about GIE?*
Should be Empty:

Parent Information

Child Information

Feeding History

Oral Eating

Therapy Experience (if any)

Family Impact