Feeding Form
Child's Name
First Name
Last Name
Gender
Male
Female
Other
Date of Birth/Age
School/Grade Level
School/Daycare Schedule
Please List Preferred Days/Times for Therapy
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about Sensory Kids?
Health Care Provider Name and Phone Number
Allergies
Yes
No
If Yes, Please List
Medications
Yes
No
If Yes, Please List
Diagnosis
Yes
No
If Yes, Please List Diagnosis
Date of Diagnosis
Provider who gave Diagnosis
Parent/Guardian Names, Relationship, Phone, Email (list all who will be involved in the child's therapy.)
Parent/Guardian Place of Employment/Job title
Check A Box
CHECK HERE IF IT'S OK TO CALL ALL PARTIES LISTED ABOVE
CHECK HERE IF IT'S OK TO LEAVE
Is there anything I need to know about contacting the people listed above?
Please list who currently lives in the home
I have the legal right to give permission for therapy services, because my relationship to the child it:
Custodial Parent
Legal Guardian
DHS Caseworker
Emergency Contact ( Name, Relationship, Phone)
Please list other professionals your child has worked with in the past (therapist tutors, counselors etc.) Name, Phone, Currently working with?
Does your child have any medical conditions? (G-tube, Seizures, diabetes, juvenile arthritis, etc.)
Recent testing (MRI, Swallow study, x-rays, hearing test, ADHD, IQ, Genetic Testing, ect.)
Any recent hospitalizations? Surgery? Injuries? (Broken bone, tonsillectomy, concussion, ect.)
Please explain, in your own words, what your child's current feeding problems. How long has this affected your life?
What have you tried to do to resolve these matters on your own? In what way (s) was this helpful?
Child's Birth Weight
Was child born full term? How many weeks?
Any pregnancy complications?
Feeding
Breastfed
Formula Fed
Combination
Feeding Comments ( i.e. picky eater, swallowing difficulties ect.)
Please describe your child's initial skill on the breast and/or bottle
During these early feedings, did your child frequently arch, cry, spit up, gag, cough, vomit or pull off the nipple? Circle the behaviors shown and describe when they would happen, and why, and for how long.
At what age was your child introduced to baby cereal?
Baby food?
Finger foods?
Table food?
When did they fully transition to table food?
Please list proteins that your child currently eats.
Please list starches that your child currently eats.
Please list vegetables that your child currently eats.
Please list fruits that your child currently eats.
Please list any foods that your child has eaten in the past, but refuses to eat now.
Describe your child's mealtime
Who typically feeds your child?
Who typically eats with your child?
What type of chair is used?
How long are meals typically?
Does your child use utensils or any type of special cups/bowls? Please describe.
Are there any other activities going on at meals? What activities?
At what times does your child typically eat during the day?
Has your child ever been on any type of special diet? If yes, please describe type of diet, at what ages, why and what was your child's response?
Has your child lost or gained any weight in the last 6 months, and how much?
Would you describe your child's weight as:
Ideal
Underweight
Overweight
Does your child take a vitamin supplement? If so, which one?
Does your child have/had any of the following problems (circle which ones)? Please describe: dental, frequent constipation, frequent diarrhea, vomiting, choking, gagging, coughing, etc.
What have I not asked about that you would like me to know?
Submit
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