Feeding Intake Form — Pediatric Case History

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Identifying Information

Note: Please bring to your evaluation, 2-3 preferred foods, 2-3 foods your child has difficulties managing, and a drink.

Child’s Name

First Name

Last Name

Goes by

DOB

Please enter a valid date that is not in the future.

Gender

Male

Female

Name of Parent/ Guardian completing this form

Family History

Father’s/Caregiver’s Name

Relationship To Child

Biological

Adoptive

Step

Foster

Other

Mother’s/Caregiver’s Name

Relationship To Child

Biological

Adoptive

Step

Foster

Other

Predominant Language Spoken at Home

English

Spanish

Haitian-Creole

Russian

Ukrainian

Portuguese

African dialect

Arabic

Other

Client lives with

Both Parents

Mother

Father

Other

Any Siblings

Yes

Is there any history of feeding, speech, language, hearing, motor, or sensory problems in other family members?

Yes

Please choose an answer.

If Yes, please describe

Educational History

School or daycare currently attending

Grade

Services your child receives at school

Are there any academic and/or behavioral difficulties reported? By whom? Please describe:

Birth and Medical History

Length of pregnancy

Delivery

Vaginal

C-section

Multiple births

Complications during delivery

Weight at Birth

Current Weight

Please list all birth history including loss of oxygen, fetal distress, NICU stay, and any other complications during pregnancy and delivery

CHECK ALL THAT APPLY. INCLUDE AN EXPLANATION FOR ANY CHECKED BOXES. IN YOUR EXPLANATION, PLEASE INCLUDE THE CLIENT’S AGE(S) IF RELEVANT, ANY DIAGNOSES MADE, AND ANY TREATMENTS THAT HAVE OCCURRED.

None

Frequent colds or is frequently congested.

Frequent sore throats or strep.

Pneumonia or aspiration pneumonia.

Mouth breathing

Snoring

Obstructive sleep or central apnea

Seasonal allergies

Sinusitis

Tracheostomy

Bronchomalacia, laryngomalacia, or tracheomalacia

Pressure equalization tubes

Hearing loss

Tonsillectomy or adenoidectomy

Lip or tongue ties released

Cardiac health concerns

Neoplasms

Has constipation or diarrhea problems

Failure to gain weight

Vomiting or digestion problems

Reflux/GERD

Esophagitis secondary to GERD

Dehydration

Frequent headaches

Seizures

Has/had a feeding tube (NG, J, G, Gavage)

If there are any Yes responses above, please elaborate below

List any conditions, disorders, or diseases of the Nervous/Circulatory/ Respiratory/Musculoskeletal systems:

List any congenital malformations, deformities, or chromosomal abnormalities.

Bowel Movement Information

Frequency per day

Consistency

Hard

Runny

Normal

Constipation

Yes

Allergies/ Intolerances

Detailed Family History of Allergies

Medications (include name, dosage, reason & any negative reactions)

Hospitalizations and surgeries?

Instrumental evaluations of swallowing function? Check any that apply.

None

Modified Barium Swallow study (MBSS)

Videofluoroscopic Swallow study (VFSS)

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Upper GI

pH probe

Please upload or bring a copy of any reports to your child’s evaluation.

Behavioral History

Check all that apply

Nervous

Hyperactive

Difficulty concentrating, short attention span

Sleepless

Wets bed

Nightmares/ Night Terrors

Sad

Shy

Easily upset

Destructive

Aggressive

Head-banging

Rocking, flapping, other self-stimulatory behaviors

Breast and Bottle Feeding History

Was the client breastfed?

Yes

Was the client bottle-fed?

Yes

During feedings did your child ever:

Frequently arch their back

Cry, scream

Spit up

Gag or Cough

Pull at nipple

Show signs of distress (shudder, grimace, turn away, splay fingers, etc)

Seem out of breath or noisy breathing

My child

Latched immediately following birth

Had trouble latching at birth, but eventually figured it out

Had trouble latching at birth and breastfeeding was unsuccessful

Has/had a shallow latch

Uses/used a nipple shield to successfully breastfeed

Uses/used supplemental nursing system (SNS)

Uses/used a finger feeder

Uses/used a syringe for feeding

Bottle Feeding

Please list any and all bottles, nipples, and/or feeding systems attempted to date:

Please add any additional information that you feel is important to share regarding breast or bottle feeding (e.g., if you worked with an IBCLC or other feeding therapist, if you needed to triple feed your baby, etc):

Feeding History

Please list the age that your child reached the following feeding milestones:

Ate cut up table foods/finger foods (ex: peas, rice, diced peaches)

Drank from a straw cup

Drank from an open cup

Used a spoon and fork independently

Weaned from pacifier

Weaned from sippy cup

When teeth erupted

Please check the following as they apply to your child:

None

Thumb or finger sucking

Nail biting

Object mouthing/chewing

Clenching/grinding teeth

Extended pacifier or sippy cup use (past 12 months of age)

Excessive drooling

Food or liquid from nose

Strong food preferences (e.g., certain tastes, textures, shapes, color, or brands)

Low volume of food

Poor appetite

Had trouble transitioning between stages of food

Is a “picky” eater

Turn head/closes mouth when food approaches

My child's a noisy eater (e.g., chomps when eating)

My child's a messy eater (e.g., food falls out of mouth)

Eats no fruits

Eats no vegetables

Has difficulty chewing; may pocket food or hold onto it for long periods of time

My child takes large bites

My child takes small bites

My child needs to swallow liquid to completely clear mouth while eating

Coughs or chokes on food frequently

My child sounds gurgly after eating

Hiccups after eating

Burps during or following a meal/snack

My child complains about stomach aches

My child eats less than 10 foods

My child eats less than 20 foods

My child has difficulty brushing teeth

List the foods the client will currently eat and drink:

Favorite Foods?

List any foods the client refuses:

Indicate with a check mark any aversions/problems or preferences your child may have.

Thin liquids (i.e. water)

Likes

Dislikes

Refuses

Difficulty Managing

Thick liquids (i.e. milkshake)

Likes

Dislikes

Refuses

Difficulty Managing

Smooth Purees (i.e. pudding)

Likes

Dislikes

Refuses

Difficulty Managing

Textured Purees (i.e. applesauce)

Likes

Dislikes

Refuses

Difficulty Managing

Mixed textures (i.e., soup with chicken and noodles)

Likes

Dislikes

Refuses

Difficulty Managing

Soft Solids (i.e., banana, cheese)

Likes

Dislikes

Refuses

Difficulty Managing

Crunchy (i.e., chips, crackers)

Likes

Dislikes

Refuses

Difficulty Managing

Chewy (i.e., meat, candy)

Likes

Dislikes

Refuses

Difficulty Managing

Hard crunchy (i.e., raw carrot)

Likes

Dislikes

Refuses

Difficulty Managing

Cold foods

Likes

Dislikes

Refuses

Difficulty Managing

Room temperature foods

Likes

Dislikes

Refuses

Difficulty Managing

Warm/hot foods

Likes

Dislikes

Refuses

Difficulty Managing

Mealtime Behaviors

Who does your child eat with?

Where does your child eat (i.e., at table, roaming, in front of TV/tablet, etc)?

In what position is your child most comfortable eating? Check all that apply

Highchair

Chair at table

Standing

Lap

Laying Down

Does your child self-feed?

Fingers

Spoon

Fork

Straw

Open cup

Does your child use any special equipment to eat?

What behaviors does your child demonstrate during mealtime? Please check all that apply:

None

Throws food

Spits food out

Leaves or tries to leave table before done

Trouble with self-feeding

Refusal to eat

Takes food from other’s plate

Has to be distracted

On average, how long does each meal take?

How many times per day does your child eat?

How long is it between meals?

How do you know if your child is hungry?

How do you know when your child is full?

Anything else you feel we should know?