• Feeding Evaluation Intake

  • In order to better understand your child's feeding skills and food repertoire, we ask that you complete the following form. After submitting this form, please also complete a separate form to log three days of your child's meals and snacks (Three-Day Food Record).

  • Foods to Bring to the Evaluation

  • Please bring one item from each category listed below to be used during the feeding portion of your child's evaluation.

    Important: If the required foods are not brought to the evaluation, the appointment will need to be rescheduled.

    • Pureed foods — applesauce, fruit puree, pudding, yogurt
    • Foods with chunks in sauce/liquid — pasta with sauce, soup, fruit in juice
    • Meltable hard solids — graham crackers, saltines, Goldfish
    • Soft mechanical foods — cheese, small pasta, lunch meats, bread, cooked veg
    • Hard mechanical foods — pretzels, cookies, raw fruits/veg, meats (chicken, steak)

  • Additional Items to Bring

    • One preferred food your child enjoys
    • One drink your child typically consumes
    • Any specific feeding items your child prefers (special cup, utensils, plates, bowls)
    • Supplemental nutrition drinks (e.g., Pediasure, protein shakes), if used
    • If your child does not eat foods from a specific food group, include one item from that group

  • Before the Evaluation

  • Please try to avoid having your child eat immediately before the evaluation. A light meal or snack earlier in the day is perfectly fine (for example, breakfast if your appointment is around lunchtime). This helps ensure your child is not overly hungry or too full, which can impact participation during the feeding portion of the evaluation.

  • If you have any questions, please feel free to contact our office at 856-275-2914. Thank you — we look forward to seeing you!

  • 1. PATIENT INFORMATION

  • Date of Birth **
     - -
  • Format: (000) 000-0000.

  • 2. FEEDING HISTORY

  • Check all that apply:*

  • PLEASE NOTE: Email any previous feeding evaluation reports and related specialist reports (GI, ENT, OT, dietician). For oral and/or pharyngeal dysphagia diagnoses, our clinical team must review reports prior to scheduling. We will not be able to evaluate your child without this.

  • Was your child diagnosed with dysphagia? **

  • 3. MEDICAL HISTORY

  • Check all that apply:*
  • Does your child have allergies?*
  • Check all that apply:*

  • Please send allergy testing results to office@mjkidz.com.

  • Any history of hospitalizations?*
  • 0/0

  • 4. ADDITIONAL FEEDING MILESTONES

  • How was your child fed following birth?*

  • Breastfeeding History

  • Check all that apply:*

  • Bottle Feeding History

  • 0/0
  • Is your child still currently utilizing external feeds?*
  • 0/0

  • 5. DEVELOPMENTAL FEEDING SKILLS

  • Eats table foods*
  • Can your child drink from a straw cup?*
  • Can your child drink from an open cup?*
  • Uses spoon/fork independently*

  • 6. WEANING HISTORY

  • Weaned from breast*
  • If not offered, check all the apply:*
  • Weaned from bottle*
  • Weaned from pacifier*
  • Weaned from sippy cup*

  • 7. CURRENT FEEDING BEHAVIORS

  • Check all that apply:*

  • 8. MEALTIME ENVIRONMENT

  • Where does your child eat? Check all that apply:*
  • Therapist-recommended highchairs include: Stokke Tripp Trapp, Abiie Beyond Junior, Keekaroo, etc.

  • 9. UTENSILS USED

  • Check all that apply:*

  • 10. PARENT INPUT

  • How serious do you feel your child's feeding issues are?*
  • 0/0
  • 0/0
  • 0/0
  • What have you tried to help your child with feeding?Check all that apply:*

  • 11. SUPPLEMENTS & DIET

  • Vitamins, minerals, herbal or nutritional supplements. Check all that apply:*
  • Is your child following a specific diet (gluten free, casein free, low fat, ketogenic, soy free, etc.)?*
  • 0/0

  • 12. REACTION TO NEW FOODS

  • Will your child taste new foods?*
  • If 'No' or 'Sometimes': what does your child do when presented with a new food? (check all that apply)*
  • Reaction to foods child does not like*

  • 13. POSSIBLE TRIGGERING EVENTS

  • Have any of these events happened that seemed to affect your child's eating, or were around the time symptoms started? Check all that apply:*

  • 3 Day Food Log

    This must be completed before scheduling your evaluation!
  • Please download this form and fill this out in entirety. You can send it to office@mjkidz.com or bring into office and submit to front desk staff. Your evaluation cannot be scheduled until this is complete. Thank you!

  • SUBMISSION

  • Date*
     - -
  • Should be Empty: