Feeding Disorders Questionnaire Page 7
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7Brief Assessment of Mealtime Behavior In Children
Date:_____________________
Think about mealtimes with your child over the past 6 months. Rate the following items according to how often
each occurs, using the following scale:
Never/Rarely
Seldom
Occasionally
Often
At Almost Every Meal
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5
Then, circle YES if you consider the item to be a problem or NO if you think it is not a problem.
How often did
Do you consider
it occur?
this a problem?
My child turns his/her face or body away from food.
1 2 3 4 5
YES
NO
My child cries or screams during mealtimes.
1 2 3 4 5
YES
NO
My child is aggressive during mealtimes (hitting, kicking, scratching others).
1 2 3 4 5
YES
NO
My child displays self-injurious behavior during mealtimes (hitting self, biting
1 2 3 4 5
YES
NO
self).
My child is disruptive during mealtimes (pushing/throwing utensils, food).
1 2 3 4 5
YES
NO
My child closes his/her mouth tightly when food is presented.
1 2 3 4 5
YES
NO
My child is willing to try new foods.
1 2 3 4 5
YES
NO
My child dislikes certain foods and won’t eat them.
1 2 3 4 5
YES
NO
My child prefers the same foods at each meal.
1 2 3 4 5
YES
NO
My child accepts or prefers a variety of foods.
1 2 3 4 5
YES
NO
My child eats mostly pureed foods.
1 2 3 4 5
YES
NO
Therapist use only:
o
Pre
o
Post
ID#______________________
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