Feeding Disorders Questionnaire printable pdf download

Feeding Disorders Questionnaire

DEMOGRAPHICS

Child’s Name:

Date of Birth:

Parent’s Name/s:

Address:

Phone Number:

Feeding/eating concerns:

Family goals for child’s feeding/eating:

Previous individuals who provided assistance with the feeding problem:

Name(s) of persons or agencies:

Address:

Phone Number:

Current Day Care or School Placement (if applicable):

Address:

Phone Number:

Medical and Developmental Diagnoses:

Medical History: Check below and describe if it’s a problem for your child

o Reflux, eosinophilic esophagitis? _________________________________________

o Delayed emptying, slow motility?_________________________________________

o Feeding tube dependence?_______________________________________________

o What are bowel movements like? _________________________________________

o Diarrhea or constipation?________________________________________________

o Ear infections? If so, when & how often?__________________________________

o Upper respiratory infections? ___________________________________________

o Pneumonia ___________________________________________________________

o Aspiration ___________________________________________________________

Food Allergies:

Dietary Requirements or Restrictions?

Feeding Disorders Questionnaire