Infant Feeding Form

Child's Name *

FirstLast

Gender*

MaleFemaleOther

Date of Birth *

Age *

Daycare Provider *

Please List Preferred Days/Times for Therapy

Address*

Street Address

CityState / Province

Postal / Zip Code

Email for Appointment Reminders*

example@example.com

How did you hear about Sensory Kids?

Language(s) Spoken at Home*

Health Care Provider Name and Phone Number*

ALLERGIES*

YESNO

IF YES, PLEASE LIST

MEDICATIONS*

YESNO

IF YES, PLEASE LIST

DIAGNOSIS*

YESNO

IF YES, PLEASE LIST DIAGNOSIS

DATE OF DIAGNOSIS

DIAGNOSIS PROVIDED BY

Name of Physician/Provider

Please provide us with a photo copy of your insurance card (front and back). Please take a photo or upload a copy of your insurance card. Note: Please make sure this card is your child's primary insurance. As a reminder, we only accept Blue Cross Blue Shield Insurance. If your child has a primary and secondary insurance under BCBS please make note of this and let our office staff know.

Insurance Card Upload:

Notes About Insurance:

I have the legal right to give permission for therapy services, because my relationship to the child is:*

Custodial parentLegal guardianDHS caseworker

Parent/Guardian Name - Primary*

First NameLast Name

Parent/Guardian Preferred Pronouns

Phone Number - Primary*

Please enter a valid phone number.Format: (000) 000-0000.

Email- Primary*

example@example.com

Parent/Guardian Employer - Primary

Parent/Guardian Name - Secondary

First NameLast Name

Phone Number - Secondary

Please enter a valid phone number.Format: (000) 000-0000.

Email- Secondary

example@example.com

Parent/Guardian Employer - Secondary

Parent/Guardian Preferred Pronouns

Voice Message Approval*

CHECK HERE IF IT'S OK TO LEAVE MESSAGES FOR ALL PARTIES LISTED ABOVE

Is there anything I need to know about contacting the people listed above?

Custody arrangements, divorce stipulations, etc

Emergency Contact (When neither guardian can be reached) *

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Relationship to Child*

Please list any specialists your babe sees: (gastroenterologist, dietician, etc.):

Has your child worked with a Physical Therapist

Has your child worked with an Occupational Therapist?

Has your child worked with a Speech Therapist?

Have you worked with a lactation consultant?

Has your child done "body work" with a specialist?

Please outline the mother's significant medical history below (medical diagnosis, surgeries, major or chronic illnesses, etc.)

Type a question

History of difficulty getting pregnant? If yes, please explain.

Have you been screened by a healthcare provider for post partum depression or anxiety?

YesNo

Does the child's mother have a history of any of the following? Select all that apply.

Does your child have siblings? If so please list ages:

Do you have family or friends who help provide care for your child?

Describe your reason for seeking our services for feeding, how long has this reason influenced you/your life/when did you first notice feeding difficulties?

Has your child had a Modified Barium Swallow Study (MBSS)? If Yes, when and what were the results.

Does your child have a history of reflux?

YesNo

Does your child have a feeding tube?

If a feeding tube is present, please outline the method of feeding (gravity, pump), time of feedings, frequency and volume of feedings.

Labor and Delivery Information*

Born Full-TermBorn PrematureVaginalC-section birth

Childs Birth Weight*

Gestational Age *

By Week

Please describe any pregnancy complications*

My child is currently

BreastfedBottle FedCombinationNeither

What difficulties are you facing with breast feeding?

What difficulties are you facing with bottle feeding?

What have you tried to do to resolve the feeding challenges on your own? In what way(s) was this helpful?

How many times a day does your child feed?

Does your child eat at night and if so, how often?

If bottle feeding, select all that apply.

using pumped breastmilkusing formulausing a mix of formula and breastmilk

Describe how much formula and/or breastmilk your child is taking in daily. If exclusievly breastfeeding, how many times a day and for about how long is each time your child is nursing?

If offering formula, which brand are you using and how is baby tolerating it?

If pumping, how many times a day are you pumping? How long is an average pump session and how much milk is expressed on average?

Have solids been introduced?

YesNo

If yes, what age were solid foods introduced?

Any issues with solid foods not described above?

Please list all the people who feed your baby (example: mother, father, nanny, etc.)

Does your baby have regular bowel movements?

YesNo

If no, please explain.

List hospitalizations, surgeries, and injuries (broken bone, tonsillectomy, concussion, etc) with dates

Recent testing not outlined above (MRI, swallow study, x-rays, hearing test, ADHD, IQ, genetic testing, etc.)

Please share anything you think is important for us to know that we may have missed:

Did child pass newborn hearing screening?*

YESNO

Has your child had a history of ear infections or tubes placed. *

Parent/Guardian Signature

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