OT Intake for Feeding Clinic Form

Child's Name*

Date form completed*

Does your child have difficulty with fine motor tasks (i.e., grasping objects)? If yes, please explain.*

Yes
No

Please explain:*

Does your child have sensory issues that interfere with their participation in daily activities?*

If yes, please fill out the Sensory Processing Checklist below.

Yes
No

Mealtime Environment:

Mealtime Schedule/Routine

Include oral and tube feeds and liquid examples

No schedule, child grazes
Second Choice
No schedule, child grazes
Night feeds via G-tube

Length of meal:*

Sequence of food/liquid presented:*

Physical Environment:

Location of Meals

At home
Restaurants
School
Other

Other Meals*

Distractions*

Television
Phone or tablet
Music
Toys
Other

Other distractions*

Seating*

Held in caregiver's lap
Highchair
Booster seat
Regular chair
Wheelchair
Adapted chair
Other

Other seating*

Preferred foods:*

Preferred liquids and volumes:*

Social Environment:

Primary feeder*

Multiple Feeds*

Does the child’s response to the caregivers feeding them differ?*

Yes
No

Explain*

List any adaptive plates/cups/utensils used:*

Describe child’s level of autonomy:*

Choices given
Clhild indicates choice
Child influences pace

Self-Care Skills

Please use the following scale to rate how your child performs self-care tasks:

Independently: Requires no assistance or supervision
Supevision:Requires monitoring, verbal directions, prompting, or set up of equipment or materials
Total Assistance:Requires caregiver to perform task
N/A (Not Applicable):Please use only if your child is too young to perform the task

My child can complete the following tasks:

Feeding:

Uses a spoon*

N/A
Independently
Supervision
Assistance
Total Assistance

Uses a fork*

N/A
Independently
Supervision
Assistance
Total Assistance

Spreads with a knife*

N/A
Independently
Supervision
Assistance
Total Assistance

Cuts with knife and fork*

N/A
Independently
Supervision
Assistance
Total Assistance

Feeding Comments:

Drinking

Drinks from a bottle*

N/A
Independently
Supervision
Assistance
Total Assistance

Drinks from a sippy cup*

N/A
Independently
Supervision
Assistance
Total Assistance

Drinks from a regular cup*

N/A
Independently
Supervision
Assistance
Total Assistance

Drinks from a regular straw*

N/A
Independently
Supervision
Assistance
Total Assistance

Drinks from a regular straw*

N/A
Independently
Supervision
Assistance
Total Assistance

Holds cup and brings to mouth*

N/A
Independently
Supervision
Assistance
Total Assistance

Drinking Comments:

Grooming:

Holds mouth open for teethbrusing*

N/A
Independently
Supervision
Assistance
Total Assistance

Holds toothbrush with caregiver*

N/A
Independently
Supervision
Assistance
Total Assistance

Brushes Teeth*

N/A
Independently
Supervision
Assistance
Total Assistance

Thoroughly brushes Teeth*

N/A
Independently
Supervision
Assistance
Total Assistance

Brushes or combs hair*

N/A
Independently
Supervision
Assistance
Total Assistance

Washes and dries hands*

N/A
Independently
Supervision
Assistance
Total Assistance

Grooming Comments:

Bathing:

Gets in/out of tub*

N/A
Independently
Supervision
Assistance
Total Assistance

Maintains sitting in tub*

N/A
Independently
Supervision
Assistance
Total Assistance

Washes and dries body*

N/A
Independently
Supervision
Assistance
Total Assistance

Bathing Comments:

Dressing:

Takes off shirt*

N/A
Independently
Supervision
Assistance
Total Assistance

Puts on shirt*

N/A
Independently
Supervision
Assistance
Total Assistance

Removes pants*

N/A
Independently
Supervision
Assistance
Total Assistance

Puts on pants*

N/A
Independently
Supervision
Assistance
Total Assistance

Takes off shoes*

N/A
Independently
Supervision
Assistance
Total Assistance

Puts on shoes*

N/A
Independently
Supervision
Assistance
Total Assistance

Takes off socks*

N/A
Independently
Supervision
Assistance
Total Assistance

Puts on socks*

N/A
Independently
Supervision
Assistance
Total Assistance

Buttoning*

N/A
Independently
Supervision
Assistance
Total Assistance

Zipping*

N/A
Independently
Supervision
Assistance
Total Assistance

Dressing Comments:

Toileting

Independent with toileting*

Yes
No
N/A

Dependent on diapers*

Yes
No
N/A

Indicates need for diaper change*

Yes
No
N/A

Indicates need for toileting*

Yes
No
N/A

Participates in toilet training*

Yes
No
N/A

Stays dry during the day*

Yes
No
N/A

Stays dry through the night*

Yes
No
N/A

Wipes after toileting*

Yes
No
N/A

Toileting Comments:

Sleep

Has difficulty falling asleep*

Yes
No

How long does it take for him/her to fall asleep?*

Has difficulty remaining asleep through the night*

Yes
No

How many hours do they sleep a night?*

Has difficulty waking in the morning*

Yes
No

Naps during the day.*

Yes
No

Naps for how long?*

Sleep Comments

Please describe your current bedtime routine and strategies used.

Play

My child:

Wanders aimlessly without purposeful play or exploration (over 15 months)*

Yes
No

Needs guidance to play, difficulty playing independently (over 18 months)*

Yes
No

Only explores objects by mouthing, banging, shaking, other*

Yes
No

Has difficulty relating objects, e.g., stacking, piling, placing in/out of containers, etc.*

Yes
No

Has difficulty with simple pretend actions, (i.e., talking on phone, feeding doll)*

Yes
No

Has difficulty playing cooperatively with others*

Yes
No

Prefers playing alone than with others*

Yes
No

Preferred activities/toys:*

Avoided activities/toys:*

Comments regarding Play behaviors:*

Social/Emotional Development:

My child is:

impulsive*

Yes
No

withdrawn*

Yes
No

easily distracted*

Yes
No

easily frustrated*

Yes
No

stubborn*

Yes
No

self abusive*

Yes
No

My child has difficulty with:

indicating wants/needs*

Yes
No

responding to interaction*

Yes
No

separating from parent or other family member*

Yes
No

accepting interaction from new people*

Yes
No

going to unfamiliar places*

Yes
No

accepting change in their typical routines*

Yes
No

accepting being told “No”*

Yes
No

moving from one activity to another*

Yes
No

moving from one location to another*

Yes
No

calming or soothing self*

Yes
No

appears to have tantrum more than other children the same age.*

Yes
No

If yes, how often?*

What does the tantrum look like?*

How do you handle discipline issues at home?*

Signs of Sensory Processing Difficulties

Please check the box beside any statement that's true for your child in the list below:

Auditory Processing

The brains ability to interpret what we hear

Makes repetitive noises
Holds hands over ears
Difficulty following a simple request
Doesn't respond to name
Difficulty with non-verbal cues
Distracted with noise
Dislikes noisy items such as vacuum, lawn mower, etc
Oversensitive to sounds

Comments for Auditory Processing

Visual Processing

The brains ability to interpret what we see

Prefers the dark
Avoids bright lights
Difficulty finding objects
Covers eye or squints in lights
Looks intensely at objects / people
Easily distracted by environment

Comments for Visual Processing

Tactile Processing

Perception of touch, the discrimination of different textures, as well as pain and temperature

Comments for Tactile Processing

Oral Processing

Awareness of textures in mouth as related to feeding, brushing teeth, etc.

Gags easily with textures / utensils in mouth
Avoids certain tastes, foods, smells
Chews or licks non-food objects
Craves certain foods
Will only eat certain foods, tastes
Drools

Comments for Oral Processing

Vestibular Processing

Relating generally to the sense of balance

Becomes distressed w/feet off ground
Dislikes riding in a car/gets carsick
Head upright even when bending/leaning
Seeks movement activities such as spinning, swinging, and jumping
Twirls/spins (likes or dislikes dizzy feeling)
Rocks unconsciously
Uncomfortable with steps
Uncomfortable with playground activities

Comments for Vestibular Processing

Proprioception

Perception of the position and movement of the body

Avoids climbing or jumping
Excessive pressure during writing and coloring tasks
Difficulty staying seated for tabletop activities
Seeks pressure
Seeks movement that interferes with daily life
Uncoordinated/clumsy, bumps objects, trips often

Comments for Proprioception

Comments

This field is for validation purposes and should be left unchanged.