PEDS Feeding Intake Form

PEDS feeding intake form

PEDIATRIC FEEDING INTAKE FORM

IDENTIFYING INFORMATION
Name*
Birthdate*
MM slash DD slash YYYY
Date of form completion*
MM slash DD slash YYYY
GENERAL FEEDING
What are your major feeding concerns?*
What feeding goals would you like your child to accomplish?*
Do you have concerns about feeding safety?*
- Yes
- No
Please describe safety concerns:*
Is there a family history of eating difficulties?*
- Yes
- No
Please describe family history of eating difficulties:*
MEDICAL HISTORY
Does your child have a history of…
- cleft lip/palate
- mechanical ventilation
- sinus infections
- failure to thrive
- gastroschesis
- EOE
- laryngeal cleft
- heart issues
- breathing treatments
- ear infections
- bowel obstruction
- dumping syndrome
- FPIES
- GE reflux
- tracheostomy
- feeding tube use
- pneumonia
- fecal impaction
- GI bleeding
- tracheomalacia
- chronic constipation
- supplemental oxygen use
- respiratory infections
- aspiration
- short bowel syndrome
- dehydration
- laryngomalacia
- other (explain in comments)
Medical History Comments
TUBE FEEDING HISTORY
Does your child have a history of tube feedings?*
- Yes
- No
Current or past?*
- Current
- Past
When did the child wean from tube?*
Tube feeding type*
- TPN
- G
- PEG
- G-J
- NG
- J
What foods/liquids are used in the feeding?*
Describe feeding schedule*
Feeding delivery*
- bolus
- pump
Bolus volume*
Pump volume*
Feeding rate*
Child’s behavior associated with tube feedings*
- tolerates well
- vomits
- sweats
- becomes lethargic
- retches
- frequent burps
- arches
- nasal regurgitation
- cries
- other (explain in comments below)
Comments about tube feedings
NUTRITION
Current weight*
Current height*
Weight loss / gain concerns?*
- Yes
- No
Describe weight loss / gain concerns*
Antibiotic exposure before, during, or after birth?*
- Yes
- No
Describe antibiotic exposure before, during, or after birth*
Describe frequency of bowel movements*
Describe consistency of bowel movements*
Mucus or blood in the stool?*
- Yes
- No
Provide specific information about mucus or blood in stool*
Describe Frequency/amount of spit ups/vomits*
History of excessive irritability/crying?*
- Yes
- No
Describe excessive irritability/crying*
History of eczema or other skin rashes?*
- Yes
- No
Describe history of eczema or other skin rashes*
Does your child express hunger?*
- Yes
- No
How does your child express hunger?*
ORAL MOTOR
Does your child present with ...
- drooling
- chronic congestion
- coughing/choking on saliva
- frequent mouthing/oral exploration of toys and objects
- open mouth resting posture
- abnormally shaped head
- thrush or thrush-like appearance of the tongue
- noisy breathing at rest
- head tilt or turn to the side
- frequent or violent hiccups
- noisy breathing during sleep
- high palate
- bubble palate
- other
Other present with*
Does your child participate in non-nutritive sucking?
- pacifier
- thumb
- fingers
- other
Other non-nutritive sucking*
Type/brand of pacifier:*
Can he/she maintain suction without adult assistance?*
- Yes
- No
Has your child been diagnosed with an oral tether (tongue/lip/cheek tie)?*
- no
- tongue
- lip
- cheek
Has your child been treated for an oral tether?*
- Yes
- No
If Yes ...*
- tongue
- lip
- cheek
Type of revision*
- laser
- scissors
- suture open
SENSORY PROCESSING
Does your child have difficulty with…*
- change in routine
- busy environments
- unfamiliar people
- unexpected or loud sounds
- bathing
- wet or soiled diapers
- riding in the car / car seat
- messy hands
- tags in clothing
- face wiping
- other
Other difficulties ...*
Is your child easily calmed when upset?*
- Yes
- Sometimes
- No
What strategies do you use to calm your child?*
BREAST/BOTTLE FEEDING
Is your child currently bottle or breastfed?*
- Yes
- No
When did your child wean from the breast/bottle?*
If answered No, answer this then you can skip to the next section
How did you originally plan to feed your baby?*
- Breast
- Bottle
- Combination
How do you currently feed your baby?*
- Breast
- Bottle
- Combination
Breast percentage?*
Bottle percentage?*
After answering, please skip to the next section.
BREAST
Did your baby experience early breastfeeding difficulties? (please describe if so)
Feeding Schedule
- on demand
- scheduled
How often does your baby breastfeed during the day?
How often does your baby breastfeed during the night?
How long do breast feedings typically last?
Breast milk supply is
- Low
- Just right
- High
Nipple shield?
- Yes
- No
- Sometimes
Preferred positioning
- cradle
- cross-cradle
- football
- biological
- laid back
- side-lying
- swaddled
Current breastfeeding skills
- functional
- has difficulty eating in unfamiliar environments
- cries upon presentation
- difficulty establishing latch
- gags
- has shallow latch/narrow gape
- needs assist with lip flange
- breaks seal/clicks
- leaks breast milk
- coughs/chokes with letdown
- bobs on/off breast
- has short duration feedings
- congested while easting
- increases breathing rate while eating
- has color changes when eating
- noisy breathing while eating
- has difficulty relaxing hands and body when eating
- moves/wiggles excessively during eating
- vomits during or after eating
- burps excessively or explosively
- arches or turns head away from breast
- reliant on bottle supplementation for satiation or adequate growth
- prefers one breast over the other breast
- falls asleep when eating
- sweats when eating
- cries when finished eating
- other
Other breast feeding skill(s)*
Mother has a history of
- nipple/breast pain
- nipple trauma
- lipstick shaped nipples
- clogged ducts
- mastitis
- other
Other history*
Mother participates in dietary restrictions
- none
- dairy
- gluten
- egg
- corn
- other
Other dietary restrictions*
Strategies used to improve intake
- distraction free environment
- dream feed (sleep)
- cluster feed
- breast massage
- other
Other strategies*
How would you like your child to improve his/her ability to breastfeed?
Additional comments about breastfeeding
BOTTLE
Did your baby have early bottle feeding difficulties?
- Yes
- No
Did you offer formula(s) in the past that were not well tolerated?
- Yes
- No
Describe those formulas*
Feeding Schedule
- on demand
- scheduled
How often does your baby bottle feed during the day?
How often does your baby bottle feed during the night?
What do you offer in the bottle?
- expressed breast milk
- donor breast milk
- fortified breast milk
- infant formula
- fortified infant formula
- other
Other(s) in the bottle*
Brand and type of formula?*
What are you using to fortify?*
How much volume do you offer per feeding?
How much volume is accepted during each feeding?
How much volume is typically accepted during a 24 hour period?
How long do bottle feedings typically take?
Bottle brand/name:
Bottle type:
- standard
- wide mouthed
Nipple brand:
Nipple type:
- single hole
- two hole
- Y-cut
- X-cut
- manually enlarger
- other
Other nipple type*
Nipple level:
- ultra preemie
- preemie
- newborn
- level 1
- level 2
- level 3
- level 4
- low flow
- medium flow
- high flow
- other
Other nipple level*
Preferred positioning for bottle feeding:
- reclined
- semi-reclined
- supported upright
- side-lying
- elevated sidling
- swaddled
- other
Other positioning*
Current bottle feeding skills:
- functional
- cries upon presentation
- gags on nipple
- difficulty establishing latch
- needs assistance with lip flange
- breaks seal/clicks
- leaks milk
- coughs/chokes
- bob on/off bottle
- has short duration feedings
- congested while eating
- increases breathing rate while eating
- has color changes while eating
- noisy breathing while eating
- has difficulty relaxing hands and body when eating
- moves/wiggles excessively while eating
- vomits during or after eating
- burps excessively or explosively
- pushes bottle, arches or turns head away from nipple
- rejects bottle if not a specific temperature
- refuses bottle from non-preferred feeders
- falls asleep when eating
- has difficulty eating in unfamiliar environments
- cries when finished eating
- sweats when eating
- other
Other skills:*
Strategies used to improve intake:
- use of thickening agents
- external pacing
- distraction-free environment
- bouncing
- rocking
- arousal techniques
- use of auditory or visual distractions
- dream feeding
- other
Describe arousal techniques*
Other strategies*
How would you like your child to improve his/her ability to take a bottle?
Additional comments about bottle feeding:
SOLID FOODS
Is your child on a special or restricted diet (gluten-free, dairy-free, etc.)?*
- Yes
- No
Describe diet restrictions*
How is your child positioned during meals?
- highchair
- booster
- adult lap
- adult chair or sofa
- roams around
- floor
- child's table/chair
- other
Highchair brand/type*
Booster brand/type*
Other positioning during meals:*
Does child participate in a mealtime at the family table?*
- yes
- sometimes
- no
BABY/PUREED FOODS
What age were baby foods first introduced?
Were there any difficulties during the initial introduction of baby foods?
Is your child currently accepting baby foods?
- yes
- no
When did child wean from baby food?
Answer and then please skip to the next section
What baby food textures are accepted?
- commercial stage 1-2
- commercial stage 3-4
- home-made pureed foods
- infant cereal
- mashed table foods
- pudding, applesauce, etc
- other
Other baby food textures:*
What pureed food groups are accepted:
- fruits
- vegetables
- meats
- grains
- blends
- other
Other pureed foods:*
How are pureed foods presented?
- adult offers pureed foods via spoon
- adult hands child a preloaded spoon
- child dips fingers, spoon or other tools in puree and brings to own mouth
- child co-feeds with adult
- eats from a pouch
- other
Others how pureed foods are presented:*
During meals, my child …
- accepts most offerings
- turns head away from spoon
- pushes spoon away
- refuses to open mouth for spoon
- spits of allows to fall out of mouth
- holds in mouth/refuses to swallow
- pushes food out with tongue
- coughs
- gags
- vomits
- cries
- loses interest quickly
- other
Other during meals :*
What strategies are used to improve intake of pureed/baby foods?
How would you like your child to improve his/her ability to eat pureed?
Additional comments about spoon feedings:
TABLE FOODS
What age were table foods first introduced?
Were there any difficulties during the initial introduction of table foods?
Does your child require a separate meal than the rest of the family?
How many meals does your child eat each day?
How many snacks does your child eat each day?
How long are meals?
Does your child eat outside of structured meal/snack times?
- Yes
- No
What are your child’s favorite foods?
What food(s) does your child consistently reject?
Does your child accept:
- fruits
- vegetables
- meat
- grains
- snacks
Does your child prefer foods that are:
- soft
- mushy
- crunchy
- chewy
- mixed texture
- bland
- spicy
- salty
- a specific color
- a specific shape
- a specific brand
- room temperature
- cold
- warm
- whole (unbroken)
- smooth
- other
Other preferred foods:*
How are table foods presented?
- self feeds
- adults hands child a preloaded fork
- co-feeds with an adult
- an adults feeds child the majority of the meal
- other
Other table foods presentation*
Are you concerned about your child’s ability to chew foods?
- Yes
- No
Please describe concerns about chewing food:*
Are you concerned about your child's ability to swallow table foods?
- Yes
- No
Please describe concerns about the ability to swallow:*
During meals, my child …
- has minimal to no issues
- refuses to come to the table
- verbally rejects food
- refuses to be confined with a tray or seatbelt during meals
- refuses food if it is not a specific brand
- refuses food if it touches another food
- is regimented about certain plates/utensils
- wants down or away before meal completion
- turns head away from presented foods
- refuses to open mouth for food
- has difficulty chewing foods
- overstuffs mouth
- holds food in mouth/refuses to swallow
- allows food to fall out of mouth
- spits food out after chewing
- plays with food excessively
- packs food in the cheeks or the of the mouth
- eats too fast
- eats too slow
- accepts a limited variety of foods
- coughs during meals
- chokes during meals
- refuses to self-feed
- vomits during meals
- is a messy eater
- seats during meals
- cries or screams during meals
- falls asleep during meals
- eats non-food items
- expresses stomach discomfort
- appears anxious
- is reliant on videos, toys, singing or other forms of entertainment
- other
Other things during meals*
What strategies are used to improve intake of table foods?
- coax
- praise
- model
- punish/discipline
- threaten
- allow to graze thoughout the day
- provide favorite foods frequently
- offer a different food when interest is lost
- entertain
- ignore
- time out
- force-feed
- offer food reward
- offer toy or activity
- iPad, TV or toy distraction
- distraction-free room
- allow grazing throughout the day
- allow to eat while roaming around home
- other
Other strategies*
How would you like your child to improve his/her ability to eat table foods?
Additional comments about table foods:
CUP/STRAW SKILLS
Does your child drink liquids from a cup/straw?*
- Yes
- No
What kind of cup?*
- soft spout
- hard spout
- recessed lid cup
- open cup
- straw cup
- other
What other cup?*
What liquids does your child accept from the cup/straw?*
- water
- milk
- juice
- soda
- other
Other types of liquids*
What temperature does your child prefer when drinking liquids?*
- room temperature
- cold
- warm
- no preference
What consistency does your child accept/prefer?*
- thick (smoothie consistency, use of thickening agents, etc.)
- thin
- other
Other consistency*
When offered liquids, my child …*
- is functional using a sippy cup
- is functional using a straw cup
- is functional using an open cup
- refuses the cup
- refuses the straw
- is unable to draw liquids through a straw independently
- coughs during cup drinking
- coughs during straw drinking
- sounds congested
- has a runny nose or watery/read rimmed eyes
- spills from the mouth before swallowing
- limits volume
- accepts a limited variety
- other
Other when offered liquids*
How would you like your child to improve his/her ability to drink liquids from a cup or straw?*
Additional comments about cup/straw drinking:
COMMENTS
Is there additional information you would like to provide that may help us better develop a plan and establish feeding strategies for your child?
Phone
This field is for validation purposes and should be left unchanged.

PEDS feeding intake form

PEDIATRIC FEEDING INTAKE FORM

IDENTIFYING INFORMATION

GENERAL FEEDING

MEDICAL HISTORY

TUBE FEEDING HISTORY

NUTRITION

ORAL MOTOR

SENSORY PROCESSING

BREAST/BOTTLE FEEDING

BREAST

BOTTLE

SOLID FOODS

BABY/PUREED FOODS

TABLE FOODS

CUP/STRAW SKILLS

COMMENTS