Feeding Questionnaire
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  • MJ Kidz Feeding Questionnaire

  • In order to obtain an understanding of your child's feeding repertoire, we request that you complete the following form. Please note that after you submit this form, you will need to fill out a seperate form for logging three days worth of meal and snack information for your child, which can be found at the following link: Three-Day Food Record. It also should have been emailed to you in the email that contained this questionnaire.

    We will need you to bring each of the following foods with you so that they can be used during the feeding portion of your child's evaluation. (Note: only one food item in each category is necessary.)

    • Pureed food such as applesauce, fruit sauce, yogurt with chunks, etc.
    • Chunks of food in sauce such as pasta in sauce, soup, etc.
    • Finger foods: any small foods such as crackers, cereals, granola, etc.
    • Meltable hard solids: able to melt in mouth with minimal saliva and pressure such as graham crackers, saltines, goldfish, etc.
    • Soft cubes: fruits, bananas, peas, etc.
    • Soft mechanicals: require minimal pressure to chew such as cheese small pastas, lunch meats, etc.
    • Hard mechanicals: biting and chewing is required such as pretzels, cookies, etc.

    In addition, please bring in a preferred food item that your child enjoys eating along with a drink.

    Thank you, and we look forward to seeing you!

  • Basic Information

  • Today's Date*
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  • Feeding History and Behaviors

  • How serious do you feel your child's feeding issues are?
  • Does your child have a history of constipation, diarrhea, gas, or reflux?
  • Has your child has any recent weight gain or loss in the last 6 months?
  • Is your child taking any vitamins/minerals, herbal or nutritional supplements?
  • Is your child currently following a specific diet (e.g. gluten free, casein free, low fat, ketogenic, soy free, etc.)?
  • Is your child averse to certain smells or textures?
  • Will your child taste new foods?
  • Have you had any help in managing your child's problems with eating?
  • Does there seem to be a behavioral problem associated with eating?
  • Does your child finger-feed?
  • Is your child still bottle-feeding or breastfeeding?
  • Does your child drink from an open cup?
  • Is this your child's preferred cup?
  • Does your child drink from a cup with a straw?
  • Is this your child's preferred cup?
  • Does your child drink from a sippy cup
  • Is this your child's preferred cup?
  • Does your child sit down for 2-3 meals, or does he/she graze throughout the day?
  • Time Required to Complete a Meal

  • How long (approximately) is spent during mealtime:

  • Types of Foods Consumed

  • Are there objections to hot or cold foods?
  • Does your child particularly like or dislike sour or spicy foods?
  • Should be Empty: