What is your primary concern? Please check all that apply.
When did you first notice your child had difficulty eating? What was the difficulty?
Has feeding been addressed with any other professionals in the past?
Does your child have a history of reflux? If so, does your child currently take medication or has s/he in the past? If applicable, please list type of medication, dates taken, and why discontinued.
How does your child currently receive liquids (e.g., bottle, straw cup, open cup)?
If tube fed (in the past or currently), what type of tube did/does your child use?
If tube fed currently, please list type of formula, times of feedings, rate of feedings, and total volume of feedings (i.e. 120cc bolus over one hour, five times per day):
Are there any specific textures that your child will not eat?
Who does your child eat with?
Where does your child eat(e.g., dining room table, kitchen island, in front of TV)?
Does your child feed him/herself?
Are distractions (e.g., toys, television, iPad) used during meals?
What is the general feeling at your mealtimes (e.g., pleasant, stressful, power struggle)?
Do you present your child with new/non-preferred foods? If so, what happens when you do?
Does your child have any food allergiesor dietary restrictions (e.g., due to personal food diets or religious preferences)? If so, please describe.
Has your child ever had a swallow study?
Do you or your pediatrician have concerns about your child's growth? Is your child followed by a dietician or nutritionist?
