PEDIATRIC FEEDING INTAKE FORM

IDENTIFYING INFORMATION

Name*

Birthdate*

Date of form completion*

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…

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*

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*

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 ...

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…*

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

Current breastfeeding skills

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:

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:

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 …

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:

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

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 …*

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?

Name

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

PEDS feeding intake form