New Patient Forms

Child's Name*

First NameLast Name

Date

FEEDING HISTORY/BEHAVIORS

What feeding concerns do you have for your child? How serious do you feel they are?

When did you first notice that your child had a feeding problem? What were the initial symptoms?

What are ways in which you have tried to help your child with his/her feeding issues?

Does your child have a history of constipation, diarrhea, gas, or reflux? If yes, please explain.

Has your child had any recent weight gain or loss in the last 6 months? If yes, please explain.

Is your child taking any vitamins/minerals, herbal or nutritional supplements? If yes, please list with dosage (mg/day).

Is your child currently following a specific diet? (e.g., gluten-free, casein-free, low fat, ketogenic, soy-free, etc.)? If yes, please explain.

List any food allergies or sensitivities your child has:

Is your child averse to certain smells or textures? If yes, please explain.

Will your child taste new foods? If not, how does he/she react when presented with a new food?

What is your child’s reaction to foods he/she does not like?

What help, if any, have you had in managing your child’s problems with eating?

Does there seem to be a behavioral problem associated with eating? If yes, how so?

How do you handle undesirable behaviors that arise during mealtimes?

Does your child finger feed? If yes, what kinds of food?

Is your child still taking the bottle or breast? If yes, how often?

Does your child drink from an open cup/straw cup/sippy cup? If yes, how many times per day is the cup used, and which type of cup is used most often?

Does your child sit down for 2-3 meals or does he/she graze throughout the day?

YesNo

If yes, by who and when?

What was the outcome of the evaluation?

YesNo

If yes, to the best of your knowledge, is it constant, sometimes, or rarely (e.g., only when sick?)

TIME REQUIRED TO COMPLETE A MEAL
How 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 CONSUMED
Please list all foods your child currently eats:   Type a label
Please list any/all foods your child used to eat but no longer does:   Type a label
Please share 2-3 foods/food types that would ideally be incorporated into your child’s diet (e.g., fruits/vegetables, proteins):   Type a label
List 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*

DAY 2*

DAY 3*

Signature*

Feeding Questionnaire