Patient Name:* DOB:* MM slash DD slash YYYY 1. Please describe your concerns regarding your child’s feeding/swallowing skills.*2. Birth History: Is there anything we should know about the birth history?*3. Medical Diagnoses and Surgeries:*4. Current Medications:*Feeding History:Was your child breast fed? How long?*Was your child bottle fed? From when to when?*Please describe your child’s initial skills on breast and/or bottle:*During these early feedings, did your child frequently cry, arch, gag, spit up, cough, vomit, turn head away from nipple? Describe the struggle behavior and when it would happen, why, and for how long:*Did your child have any difficulty weaning from breast and/or bottle? Describe if the weaning process was difficult:*At what age your child transitioned to Baby cereal? Baby Food? Finger Foods? Transitioned fully to table foods? Describe any difficulties with transitioning:Please answer the following questions if your child eats by mouth:List all the foods that your child will eat or drink:List the foods that your child refuses:List all food allergies:Describe your child’s mealtimes:Who feeds your child? Who typically eats with your child? What type of chair is used during feeding? How long the meals take? Does your child use utensils or any special types of spoons or bowls?Are there any other activities going on at meals? What activities?Describe your child’s meal schedule on a typical day:Please answer the following questions if your child is tube fed:What type of formula is the child receiving? Also describe how you mix it?Please detail your child’s feeding schedule below:Feeding how often (e.g. every four hours, four feedings per day etc.): What type of feeding tube (NG, G, GJ, or J tube?): What method do you use for feeding? (Gravity feeding/Feeding pump/Bolus feedings-via syringe) If feeding pump is used, feeding at what rate? Describe your child’s behavior during and after tube feeding?All please answer the following questions:Does your child struggle with teeth brushing?How often does your child have a bowel movement? Any constipation Issues? Please describe?How do you know if your child is hungry or full?Has your child lost or gained any weight in the last six months? How much?Describe your child’s weight as: (Ideal, underweight, overweight?) Describe how you and your child feel after feeding?You: Your child: What other evaluations have been completed regarding your child’s feeding difficulties and what were the results or what were you told?What treatments have been tried for this problems, and what were the results?What would you like from us? How can we be helpful to you and your child?
