Feeding Program Intake Form - Part 1

Feeding Program Intake Form - Part 1
Patient Name
DOB
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.

On the following pages check off foods your child currently eats by choosing plus for that item. If your child previously accepted a food item, but no longer eats that food please choose minus for that item.

This will help your therapist identify patterns in accepted and rejected foods. Feel free to write in specific brand names of food items in the comments at the bottom 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.
Please list your child's favorite foods/liquids:
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Please list your child's least-favorite foods.
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What goal foods would you like to see your child eat with the rest of the family?
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Therapy Associates, Inc.
Are there times when your child eats well?
Where does your child typically eat?
What do they 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 he/she dislikes?

Therapy Associates, Inc.
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?
Additional Comments:
Fast Foods
Please list what fast foods they like and what they will eat.