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OT Intake for Feeding Clinic
OT Intake for Feeding Clinic Form
Child's Name
*
Date form completed
*
MM slash DD slash YYYY
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
Avoids getting messy
Discomfort with brushing teeth
Distressed during grooming
Prefers long sleeve when hot / short when cold
Doesn't notice messy hands / face
Sensitive to certain fabrics
Irritated with socks / shoes
Reacts strongly to touch
Rubs / Scratches spots that have been touched
Unusual need to touch objects / people / surfaces
Decreased awareness of pain / temperature
Decreased awareness of touch
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.