Feeding History Form

Child's Full Name

First NameLast Name

Date of Birth

Date

Is child currently taking any medication?

YesNo

Please list them.

Does child have any allergies?

yesno

Please list them.

Was your child breast fed?

YesNo

From when to when:

Was your child bottle fed?

yesno

From when to when?

Please describe your child's initial skill on the breast and/or bottle:

3. During these early feedings, did your child frequently arch, cry, spit up, gag, cough, vomit or pull off the nipple? Describe when they would happen, and why, and for how long:

4. Describe how the weaning process off the breast and/or bottle went and why the child was weaned:

At what age was your child introduced to
baby cereal   age
baby food   age
finger foods   age
table food   age
When did they transition completely to table food?   age

Please describe how these transitions were handled by your child, especially if any difficulties happened:

IF YOUR CHILD EATS BY MOUTH, PLEASE ANSWER THE FOLLOWING QUESTIONS:
6a. List the foods that your child currently will eat and drink (put a star next to their favorites). Please be specific on brand/preparation (raw, cooked, flavor added).
Fruits   Please list
Vegetables   Please list
Meats   Please list
Dairy   Please list
Other   Please list

List the foods your child refuses:

List the foods your child is allergic to:

Describe your child's mealtime:
Who typically feeds your child?   Please list
Who typically eats with your child?   Please list
What type of chair is used?   Please list
How long are meals typically?   Please list
Does your child use utensils or any type of special cups/bowls?   Please list
Are there any other activities going on at meals?   Please list

What times does your child typically eat and what type of meal?

IF YOUR CHILD IS TUBE FED, PLEASE ANSWER THE FOLLOWING QUESTIONS:7a. What type of formula is used and exactly how do you mix it?

7b. TUBE FEEDING: Describe where your child is tube fed and what activities are occurring at the same time:

7c. TUBE FEEDING: Describe your child’s reactions to the tube feedings (connecting, during, disconnecting):

7d. TUBE FEEDING: Please detail your child’s feeding schedule below.

8. Has your child ever been on any type of special diet other than what you just described? If yes, please describe type of diet, at what ages, why and what was your child’s response:

9. How do you know your child is hungry or full?

10. Has your child lost or gained any weight in the last 6 months, and how much?

11. Would you describe your child’s weight as:

IdealUnderweightOverweight

12. Does your child have/had any of the following problems:

Please describe:

13. Does your child take a vitamin supplement? Which one?

14. Describe how you, and your child feel after a feeding:

15. What other evaluations have been completed regarding your child’s feeding difficulties and what were the results/what were you told?

16. What treatments have been tried for this problem, and what were the results?

17. How can we be most helpful to you and your child?

Food History: Please include the foods your child has ate and about how much over the last 3 days: