Feeding Program Intake Form

Feeding Program Intake Form
Thank you for contacting us to consult about your child’s tube-feeding needs. Please fill out the form below with as much detail as you can, and feel free to contact us with any questions at (323) 709-3099.

Upon receipt of this intake form, our team of professionals will validate that it is safe to proceed with our consultation services and provide you further information around options available to you and your child. We cannot approve ANY weaning plan without evidence of a safe swallow as observed by a therapist, physician, or radiological exam (swallow study). Please be sure to include this information in the intake below.
Date

MonthDayYear
Date
Parent/Guardian Name (Primary Contact)*

First NameLast Name
Parent/Guardian (PC) Preferred Pronouns
Parent/Guardian Name (Contact 2)

First NameLast Name
Parent/Guardian Name (Contact 3)

First NameLast Name
Parent/Guardian (C3) Preferred Pronouns
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email Address*
example@example.com
Time Zone*
Best Time to Contact
Phone Number*
Child Information
Child's Name*

First NameLast Name
Child's Gender Assigned at Birth

MaleFemale
Child's Preferred Pronouns
Child's Date of Birth

MonthDayYear
Date
Biological Mom's Height
Biological Dad's Height
Was your child born premature? (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 Height*
Please indicate if you are documenting in pounds and ounces or grams and kilograms.
Date measurements were taken?

MonthDayYear
Date
Has your child been able to maintain a steady growth curve with tube feeds, at any percentile?*
Current known allergies:
Current medications:
Feeding/Medical History
How was your child fed at birth?*
i.e. nipple/gavage, breast fed, TPN, NG tube, etc.
What was the first sign of eating issues?*
e.g. coughing, choking, refusal to eat, etc.
Please check the box to indicate if your child has had any of the following medical conditions. Select all that apply.*

Genetic Disorder/Chromosomal AbnormalityNeurologic DisorderCongenital Heart DiseasePulmonary/Respiratory ProblemsRena DiseaseDigestive/Gastrointestinal DisordersOncology/Hematology DisordersAutism Spectrum DisorderFeeding and Swallowing DisorderOther/Note
Please provide any additional/specific medical detail here:*
Please list all surgical procedures completed:*
Do you anticipate future surgeries?
If yes, what procedure? AND when do you anticipate it being performed?
Feeding Tube Placement
How old was your child when the initial tube was placed?*
Please indicate in years and/or months
What kind of tube was it?*
e.g. NG/OG, NJ, ND, etc.
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/OG, NJ, ND, surgically placed GT, surgically placed JT, surgically placed GJ-tube
Was a fundoplication performed?

YesNo
Have you previously attempted a tube wean? If yes, when?
Feeding Tube Use
Feeding Tube Use
Please list what 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 or under 1hr via pump) or by continuous pump (over 1hr per feed or continuous over night, etc)?*

BolusContinuous Pump
If bolus feeds, how are they delivered and how fast? (ie, syringe or pump or gravity and in 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 current issues with reflux or constipation? If so, how is it managed?
Does your child have any difficulties with tube feed toleration? If so, please list. Provide as much detail as you can.
e.g. granulation, rash, frequent removals or changing, vomit, retching, etc.
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?
Has anyone on your medical team -- physician or feeding therapist -- observed your child’s swallow? What were their thoughts regarding the swallow’s safety?*
Did your child eat orally at all before the tube was placed?*

YesNo
If yes, how was the experience for both you and your child? Please describe.
e.g. slow, fussy, stressful, relaxed, etc.
Did the oral eating change over time until the tube was placed?*

YesNo
If your child ate before the tube, how did his/her eating change after the tube?
Does your child eat anything orally now?

YesNo
If no, please describe how your child responds when he/she/they is given the opportunity to eat:
If yes, please list foods and quantity:
Do you use rewards, distractions to encourage eating?
e.g. TV, phone, 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?
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)
If you selected other, please describe:
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

We know that tube-feeding can be a “normal” experience or a highly stressful one. In this section, we are asking how tube-feeding is impacting your life, and any specific concerns that you have.
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?
THANK YOU for taking your time in completing this intake form. This will help us to get to know you and more about your child before we proceed with the session. We will be reaching out to you very soon. It would be our pleasure to be part of this wonderful journey!
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