Blenderized Tube Feeding Intake Form

Date

MonthDayYear
Today's Date
Parent/Guardian Name (Primary Contact)*

First NameLast Name
Parent/Guardian (PC) Preferred Pronouns
Parent/Guardian (PC) Email*
example@example.com
Parent/Guardian Name (Contact 2)

First NameLast Name
Parent/Guardian (C2) Preferred Pronouns
Parent/Guardian (C2) Email
example@example.com
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Zip CodeCountry
Time Zone*
Child's Information
Child's Name*

First NameLast Name
Child's Gender Assigned at Birth
Child's Preferred Pronouns
Child's Date of Birth*

MonthDayYear
Date
Was your child born prematurely (less than 37 weeks gestational age)?*
If yes, how early(e.g., 32 3/7 weeks)?
Child's Weight at Birth*
Please indicate if you are documenting in pounds and ounces or grams and kilograms.
Child’s Length at Birth*
Please indicate if you are documenting in inches or centimeters.
Child's Current Weight*
Please indicate if you are documenting in pounds and ounces or grams and kilograms.
Child's Current Length/Height*
Please indicate if you are documenting in inches or centimeters.
Date Current Measurements Were Taken*

MonthDayYear
Date
Has your child been able to maintain a steady growth curve with tube feeds, at any percentile?
Current medications:*
Current known food allergies:*
Any cultural or religious preferences or food intolerances that need to be taken into account?
Any vitamins or minerals that are restricted in the diet? Why?*
Any vitamins or minerals that need to be enriched in the blend due to history of deficiency?*
Medical History
Please check the box to indicate if your child has had any of the following medical conditions. Choose all that apply.

Genetic Disorder/Chromosomal AbnormalityMetabolic DisorderNeurologic DisorderCongenital Heart DiseasePulmonary/Respiratory ProblemsRenal DiseaseDigestive/Gastrointestinal DisordersOncology/Hematology DisordersAutism Spectrum DisorderFeeding and Swallowing Disorder
Please provide additional/specific medical detail here.
Please list all surgical procedures completed:
Does your child have current issues with reflux or constipation? If so, how is it managed?
Feeding Tube Placement
How old was your child when the initial tube was placed?*
What was the reason for tube placement?*
(e.g., medical stability, respiratory problems, refusal to eat, etc.)
What tube do you have now?*
(e.g., NG, ND, NJ, surgically placed GT, surgically placed JT, surgically placed GJ-tube)
If you have a gastrostomy tube (GT), what size is it?
(e.g., 12 Fr., 14 Fr., 16 Fr., or 18 Fr.)
Was a fundoplication performed?
Feeding Tube Use
Please list what formula or blend you put in your child's tube, how much you put, and what times you feed.*
Are your tube feeds delivered as a bolus feed by syringe, large bore gravity bag, bolee bag, or pump?*
How fast are tube feeds delivered?*
(e.g., over how many minutes)
If continuous, how many consecutive hours at a time are they running, or for how many minutes if feeds run longer than 1 hour?*
Does your child have any difficulties with tube feed toleration?*
If so, please list. Provide as much detail as you can.
Oral Eating
Does your child eat anything orally now?

YesNo
If yes, please list foods and quantity:
Do you use rewards, distractions to encourage eating?
(e.g., TV, phone, music, etc.)
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?
Development
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?
How do you think your child will benefit from a diet of blended foods?
Is there anything else we need to know?
Should be Empty:

Child's Information

Medical History

Feeding Tube Placement

Feeding Tube Use

Oral Eating

Development

Family Impact