2021 Feeding Questionnaire

Feeding Questionnaire
ACCESS CODE*
Child's Name*
Child's Date of Birth*

MonthDayYear
Date
Parent Name*
Email*
example@example.com
What are your feeding concerns?*
What illness or surgical procedures has your child had?*
Is your child on any medication?*

yesno
If yes, please list
Does your child's pediatrician have a concern for weight gain?*

yesno
What previous feeding assessments has your child had?*
If none, please write N/A.
Has your child had a Modified Barium Swallow Study, or a Videofluoroscopy Swallow Study?*

yesno
Have you received a consultation with a dietician?*

yesno
Is a dietician currently working with your child?*

yesno
If yes, who? How often?
Has your child seen any specialists related to the feeding concerns, such as a Gastroenterologist?
If no, please write N/A.
Is your child receiving therapy? (Click all that apply)*

occupational therapyphysical therapyspeech therapynone
If yes, with whom?
Does your child attend a preschool or school program?*

yesno
If yes, where?
Please mark early feeding history:*

breast-fedbottle-fedg-tubeng-tubegj-tube
What was challenging about feeding your child when he/she was an infant?
What formula(s) was your baby on?*
If none, please write N/A.
How did your baby tolerate formula?*

Tolerated wellDid not tolerateGagged
When did you introduce pureed foods (e.g., First Foods or homemade)?*
How did your child do with pureed foods?*
How did your child do with the transition to lumpy and solid foods?*
When did the feeding problems begin?*
How often does your child eat and drink? What are his/her usual meal and snack times?*
What foods/liquids does your child usually eat for:
Breakfast (list amount/volume)*
Lunch (list amount/volume)*
Dinner (list amount/volume)*
Snack(s) (list amount/volume)*
Including which of the following types of foods:*

Regular liquidThick liquidCommercial pureed baby First or Second FoodsPrepared in the blenderGround or commercial Third FoodsMashed soft table foodsRegular table food (easy)Regular table food (hard)
Which of these types of foods are easiest for your child?
Which of these types of foods are hardest for your child?
What do you usually use when feeding your child? (Check all that apply.)*

BreastFingersSpoonForkCupBottleStraw
Which of the following can your child use independently?*

ForkFingersSpoonCupBottleStraw
Does your child have favorite food tastes? What are they?*
Does your child have favorite food textures? What are they?*
Does your child prefer food at a certain temperature?*
Who usually feeds your child?*
Who else can feed your child?*
Where is your child fed (e.g., in a chair, on your lap)?*
How long does it take to feed your child?*
What is the average amount of food and liquid your child takes during that time?*
Does your child have any food allergies that you are aware of?*
If none, please write N/A.
Do any other family members have allergies (e.g., food, chemicals, pollens, molds)?*
Does your child currently have problems with and/or have a history of the following:
Gagging?
Please describe.
Current problemPast problem
Choking?
Please describe.
Current problemPast problem
Gastroesophageal Reflux?
Please describe.
Current problemPast problem
Traumatic experiences around feeding?
Please describe.
Current problemPast problem
Other comments:
Should be Empty: