Feeding History Form

FEEDING HISTORY FORM

Over Age 2
Patient Name*
Date of Birth*
Date*

MonthDayYear
Date
Instructions prior to arrival for feeding appointment: All forms must be completed prior to arrival. Allow your child a small meal or snack 2 hours before scheduled appointment. Your child should be hungry, but not uncomfortable prior to arrival.
Please list at least 5 of your child's favorite foods/liquids:
Please list your child's least favorite foods/liquids:
What goal foods would you like to see your child eat with the rest of the family?
Are there times when your child eats well?
Where does your child typically eat?
What does your child sit on/in to eat?
Who typically feeds your child?
What is your child's mealtime routine (i.e. at the table together, by themselves)
What is your child's response when presented with foods they dislike?
Is your child taking any medications?
Does your child have any allergies/sensitivities to foods?
Are there any foods your family doesn't eat due to cultural, religious, or personal beliefs?
What are your feeding/mealtime goals for your child?
Please list what fast foods they like and what they will eat:
Overall Description of your child's appetite:

PoorFairGoodVaries from day to day
Additional Comments

On the following pages select a (+) from the dropdown if your child currrently eats an item. Select a (-) if your child previously accepted a food item, but no longer eats that food. Select the blank dropdown if the item has not been tried by, or introduced to the child.

This will help your therapist identify patterns in accepted and rejected foods. Specific brand names of food items can be added following the tables to help with analysis. We can use this form in later treatment to reevaluate the amounts and types of foods your child accepts.

We also analyze favorite and least favorite foods for patterns and similarities.

Texture Preferences:

	(+/-/BLANK)
Crunchy
Crisp
Smooth
Lumpy
Uniform lumpy (cottage cheese)
Hard
Chewy
Mixed consistencies

Taste Preferences:

Temperature Preferences:

Breads:

	(+/-/BLANK)
Crackers
Pretzels
Bugles
Tortilla chips
Flour tortillas
Pizza crusts
Bread (white, wheat, rye, potato, pumpernickel, rice, gluten-free)
Garlic bread sticks
Hot rolls, baked bread, crescent rolls, & croissants
Doughnuts, sweet rolls, cinnamon rolls, & caramel rolls
Corn bread
Cake, pies, & other pastries
Cookies
Chips
Snack mix
Cheese Puffs
Taco shells (hard)
Rolls
Hamburger or hot dog buns
Plain Breadsticks
Garlic Toast
Biscuits
Banana bread, pumpkin bread, apple bread, & muffins
Cupcakes
Cheesecake

Nuts:

Meats:

Condiments:

Potato Products:

	(+/-/BLANK)
French fries
Tater rounds
Fried potatoes
Potato wedges
Mashed potatoes
Mashed potatoes with gravy
Baked sweet potatoes
Sweet potato chips
Vegetable chips
Tater tots
Hash Browns
Potato chips
Shoestring potato sticks
Mashed potatoes with butter
Scalloped/au gratin potatoes
Candied sweet potatoes
Sweet potato fries

Breakfast Foods:

	(+/-/BLANK)
Oatmeal
Pop-Tart (frosted or plain)
Pancake with fruit
Homemade waffle
French toast
Egg omelet
Boiled egg
Egg with cheese, vegetables, salsa, meats, etc.
Toast with jelly
Toast with peanut better
Breakfast shake
Cream of wheat
Dry cereal
Pancakes with syrup
Frozen waffle
Scrambled egg
Fried egg
Poached egg
Toast with cinnamon and butter
Toast with apple butter
Toast with honey
Yogurt

Soups:

Cheese & Dairy:

Vegetables:

Pastas/Italian Style Dishes:

	(+/-/BLANK)
Spaghetti
SpaghettiOs/Ravioli
Pizza
Lasagna
Casserole (i.e. Hamburger Helper)
Pizza toppings

Fruits:

Other Foods:

Liquids:

Please specify any unmentioned foods that your child currently eats, or used to eat:
Are there specific brands, or flavors your child prefers?
Select which tools your child uses:

Open cupBottleSippy cupSpoonForkOther
Additional Comments:
Should be Empty: