Feeding Clinic Intake Packet

Gestation Number Weeks Number Days

Birth WeightNumber LBS Number Ozs

If yes, date of Decannulation Date   Brand/Size   List   
Reason for Placement   Describe   Date of Placement   Date   
Complications (if any)   Type a label   
Date of most recent endoscopy   Date   
Tolerance of speaking, valve/capping:     Yes   No     
Type and size of speaking valve:   Type a label   
Frequency of suctioning:   Type a label   
Viscosity/ Color of secretions:   Type a label   

Currently on Oxygen?   Yes   No     
Oxygen use in the past:   Yes   No   
If yes to either
Via:     Please Select Type Option 1 Type Option 2 Type Option 3    
Frequency   Type a label   Amount   Type a label   
O2   Type a label    Liter Flow   Type a label    
Ventilator dependency     Please Select Type Option 1 Type Option 2 Type Option 3            
Oral Suctioning   Yes   No  
Frequency of Oral Suctioning   Type a label    

Cardiac History   Yes   No    
If yes:
Type of Problem:blank
Related Surgery:   Type a label   
Episodes of cyanosis:   Yes   No   

Cranio-Facial History   Yes   No   
Type:   Complete (hard,soft palate and lip)   Incomplete(Soft Palate only)   Incomplete(Lip Only)  Sub Mucus Cleft    
Please Indicate Left   Right 
Please Indicate   Bilateral   Unilaterall         
Select any that apply:   Retrognathia(small jaw)   Nasal Regurgitation(through nose)    Ear malformation   Dental Abnormalities                 

Alternate Feeding:   Yes   No  
Type:
G-Tube   NG-tube   PEG Tube   GJ Tube   J-Tube   TPN       
Site Care Routine   Site Care   
Size   Size   
Balloon:   Balloon   
Type:   Type   
Date of Insert:   Date   
List of any complications:     
Fundoplication:   Yes   No    
Related Surgeries:   Type a label   

Please answer if applicable
Bottle/Nipple used for feeding
Formula/EBM: blank
Oz consumed per bottle:   Number   oz
Length of Avg bottle time   <than 5 mins   5-20 mins   20+ mins 
Who is the primary feeder(mom,dad,other)       
Primary Position   Supine   Side-lying   Elevated   Cradle
Food temperature preference   Warmed    Chilled    Variable   
Daily Volume in ounces       oz
Modifications to feed:   Type a label                     

Typical time(in minutes) spent breastfeeding on each breast
Left   Number  Right   Number   
Nipple Shield   Yes    No  
Milk Production   Excessive, more than child needed   Average   Low, not enough to meet child's needs        
Feeding Time   Scheduled    On Demand           
Child's response to feeding   Vigorous    Lethargic    Fussy    Comfortable    Variable            
Select all that apply   Child frequently spits up   Child frequently vomits    Child shows extreme discomfort during/after feeding               

List the following ages (in months) when the child did the following:
Walked Alone:   Months   
Spoke first word   Months   
Used 2 word phrases:   Months   
Understood and followed simple instructions:   Months   
Toilet Trained   Months