Feeding Intake Form

Feeding Intake Form

Please complete the following information to make your visit as productive as possible.
First and last name of person completing this form.

First NameLast Name
First and last name of patient

First NameLast Name
Phone Number
Please enter a valid phone number.
Child lives with:

Parent(s)Grandparent(s)Sibling(s)Other
List any family members with related speech, feeding, cognitive, physical, hearing, and/or physical disabilities.
Primary Language:
Education (Check all that apply):

DaycarePreschoolPrivate SchoolPublic SchoolFull-timePart-time
Has your child ever received any of the following services at school privately?

Speech TherapySpecial EducationPhysical TherapyOccupational TherapyCounseling
Feeding Milestones
Breast

Latched immediately following birthDifficulty latching from the start, but figured it outDifficulty latching from the start, unsuccessful with breastfeedingDid not attempt breastfeeding
List all bottles or feeding systems attempted to date ands success with each.
Age transitioned to purees?
Age transitioned to solid food?
My child eats cut-up table foods.

YesNo
My child drinks from a straw cup.

YesNo
My child drinks from an open cup.

YesNo
My child uses a spoon/fork.

YesNo
Additional habits (Check all that apply):

Finger/ object suckingLip licking, sucking, bitingClenching teethExcessive droolingLow volume of food consumedNoisy eaterTakes overly small or large bitesEats less than 10 foodsBurps oftenNail bitingGrinding teethLow appetiteFeeding tubeMessy eaterCoughs/ chokesHiccups after eatingHas difficulty chewing
Where does your child sit during meals?

Infant seatHigh ChairBoosterCaregiver's armsAdult chairStandsWandersCaregiver's lapSofaCribBedCar seat
Check all utensils used to feed your child.

SyringeOpen cupNosey cupStraw cupBottleBreastSippy cupStrawInfa-trainerSpoonForkPlate guardDivided plate
Did your child eat their first birthday cake?

YesNo
Speech & Language Milestones
Does your child (check all that apply):

Babble (baba)Use jargon (long strips of babble)Speaks meaningful wordsCombines words (more all)
My child understands:

Most of what I saySome of what I sayNothing I say
My child communicates using:

Spoken wordsGesturePhotosSigns
Social History
My child prefers to:

Play alonePlay with othersBoth
Upcoming Visit
What are you hoping to gain from an evaluation today?
Texture preferences- My child prefers:

CrunchyCrispLumpyHardSmoothChewyUniform lumpyMixed
Taste preferences:

SaltySweetSpicyTartFlavoredBland
Temperature preference:

HotWarmColdCool
Appetite:

PoorFairGoodVaries
Best time to eat:

MorningAfternoonEveningNight
Accepted Foods by Category

Please check all foods currently accepted by your child.
Breads:

CrackersSnack MixFlour TortillaRollsHot Dog BunsGarlic BreadsticksBiscuitsMuffinsCorn BreadPastriesChipsBuglesTaco Shells (Hard)Pizza CrustBreadGarlic Texas ToastDoughnutsBanana BreadCake/ CupcakesCheesecakePretzelsCheese PuffsTostitos/ Corn ChipsHamburger BunPlain BreadsticksHot RollsCinnamon RollsPumpkin BreadPiesCookies
Meats:

Baked ChickenFried ChickenChicken StripsChicken NuggetsTurkeyPoultryFried FishBaked/ Broiled FishTunaSalmonBeefRoastRibsVenisonHamburgerSteakHamVealPorkSausageBaconHam/Tuna/Chicken SaladMeatballsHot DogCorn DogLunch MeatBaby Food/ Pureed Meats
Nuts:

PeanutWalnutCashewPecanAlmondNut ButterOther
Potato Products:

FriesTater TotsHash brownsBaked PotatoWedgesMashed (Plain)Mashed (Butter)Mashed (Gravy)Au GratinSweet PotatoCandied PotatoSweet Potato FriesSweet Potato ChipsChipsVegetable Chips
Breakfast Foods:

OatmealCream of WheatPop TartsDry CerealPancakes + FruitPancakes + SyrupHomemade WafflesFrench ToastScrambled EggsOmeletHard Boiled EggsPoached EggsEggs + SidesToast with ButterToast with JellyToast with Nut ButterToast with HoneyBreakfast ShakesYogurtGritsFresh FruitSmoothiesOther
Vegetables:

Green BeansBroccoliCauliflowerCornSquashCucumberZucchiniSpinachCarrotsLettuceColeslawCabbageSweet PotatoTomatoesAsparagusOnionPeasSalsaBaby Food VeggiesOther
Liquids:

Fruit JuiceLemonadeWhole Milk2% Milk1% MilkUnsweetened TeaSodaSweet TeaMilkshakeFloatsDrinkable YogurtWaterSupplementsOther
Grain Dishes:

SpaghettiLasagnaRavioliPizzaPizza ToppingsCouscousQuinoaRiceCasseroles
Soups:

CheeseCheese & BroccoliCheese & VegetableChiliStewVegetarianVegetable & BeefFrench OnionEgg DropBeed NoodleChicken NoodleChicken & RiceOthers
Dairy:

CheddarAmericanParmesanSwissMonterey JackMozzarellaColbyCottage CheeseSour CreamYogurtCool WhipIce CreamSherbertOther
Favorite Foods/ Liquids:
Least Favorite Foods/ Liquids:
Goal Foods:
Please share any additional information you feel may be useful in review your child's current and/or previous accepted foods.
Should be Empty:

Feeding Intake Form

Feeding Milestones

Speech & Language Milestones

Social History

Upcoming Visit

Accepted Foods by Category