FEEDING HISTORY/BEHAVIORS
TIME REQUIRED TO COMPLETE A MEALHow long does it take for your child to complete a meal in total? Type a label How long (approximately) is spent during mealtime:Eating Type a label Drinking Type a label Playing with food/fidgeting Type a label Avoiding/protesting Type a labelOther (describe) Type a label
TYPES OF FOOD CONSUMEDList foods that your child particularly likes. Are there objections to hot or cold foods? yes no If yes, describe: Does your child particularly like/dislike sour or spicy foods? yes no If yes, describe: What kinds of foods are easiest for your child to eat? Give examples. What kinds of foods are hardest for your child to eat? Give examples. In what way are they easy or difficult?
3-DAY FOOD RECORD:
To the best of your ability, please record your child’s food and beverage intake for 3 days. Please be as specific as possible and list portion sizes (e.g., 1/2 cup blueberry yogurt; 4 oz. apple juice). Please be sure to list all snacks and treats as well (e.g., 10 Skittles; 5 crackers).
DAY 1:
Breakfast Type a label*
Lunch Type a label*
Dinner Type a label*
Snacks Type a label*
DAY 2:
Lunch Type a label* Dinner Type a label* Snacks Type a label*
DAY 3:
Breakfast Type a label* Lunch Type a label* Dinner Type a label* SnacksType a label*