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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.