• Child Feeding Case History Form (6 Months-10 Years)

    Please complete this information and submit. If you have any previous evaluations or reports that you feel would be helpful, please send them along with this form.
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • List Pediatricians/ Physicians Names
  • Appointment Availability

  • General Questions

  • Has your child received a feeding evaluation in the past?
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  • Family Information

  • Relationship to Child
  • Relationship to Child
  • Format: (000) 000-0000.
  • Client (Child) lives with...
  • Children in the family*
  • Others living in the home*
  • Select any family stressors that may impact the client's (child's) behavior:

  • This is a fill in the field. Please add appropriate fields and text.

  • Birth History

    For the child being evaluated

  • What was the baby's birth weight?
    birth length? .

  • What was the condition of the infant while in the nursery? Please mark "no" or "yes" in the respective column and explain below.
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  • Medical History

  • It is very important to have as complete a medical history for the client as possible. Please fill out the grid below, making sure you include an explanation for any question answered "yes". In your explanation, please include the client's age(s) if relevant, any diagnoses made, and any treatments that have occurred/
    Rows
  • Hospitalizations and/or Surgeries? Date(s) & reason(s)

  • Feeding History

  • Was the client (child) breast-fed?
  • Was the client (child) bottle-fed?
  • During these early feedings, did the client frequently:
  • Has the client ever been on any type of special diet other than what you just described?
  • Describe a typical meal. Include what your child eats, drinks and how much of each:
    Rows
  • Which of the following does your child drink?
  • Indicate any aversions/problems or preferences your child may have. Included are examples of each food group.
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  • Does your child have food preferences based on color, shape, flavor (sweet, salty, sour)?
  • Does your child use any of the following special equipment to eat?
  • Does your child self-feed?
  • How?
  • Is your child tube-fed?
  • Please detail the client (child) feeding schedule below:
    Rows

  • Developmental/Social History

  • We would like to have information about the client's developmental milestones. Indicate the age when the client first performed each of the following INDEPENDENTLY. If you can not recall/find a specific age, please mark whether you believe your child accomplished the milestone early, on time, or late. If the client has not yet achieved the milestone, write N/A in the age column. Please rate your estimation of the quality of your child's skills.

  • Milestones:
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  • Do you feel the client was "faster' or "slower" than her/his peers in any other way?
  • Any special education services?
  • Has the client had any problems with any of the following (beyond expected for the child's age):
    Rows
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: