Feeding Disorders Questionnaire Page 3
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77. Mealtime Schedule: Please indicate mealtimes, and amounts of foods typically eaten
Meal
Time
Typical Foods and Amounts
Bfast
Snack
Lunch
Snack
Dinner
Snack
8. What does your child drink each day?
9. How much?
10. Are foods and drinks restricted or available when your child asks?
11. Tube Feeding Information - if applicable
Current Tube type:
Percent of daily calories via
tube:
Type of Formula:
Bolus or Continuous:
Vomiting or other problems
with tube feedings:
12. Tube Feeding Schedule: Please indicate times and amounts of tube feedings. If
applicable
Times
Amount
FOOD PREFERENCES AND MEALTIME BEHAVIORS
1. At what point does your child start to refuse foods- visual/sight, smell, touch, taste?
2. Can your child tolerate nonpreferred foods on his/her plate? On the table?
3. Does your child show interest in other people’s food?
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