Feeding Intake Form | Lori Kilpatrick Pedi

Feeding Patient Intake Form

FEEDING NEW PATIENT INTAKE FORM

Please complete the new patient Feeding history information intake form below.

CHILD INFORMATION

Child Full Name

Child Date of Birth

Parent/Legal Guardian Name

Phone

FEEDING HISTORY

In your own words, describe your child's feeding problems.

Was your child breast fed? Until what age?

Was your child bottle fed? What age did he/she start? what age did they stop?

please describe your child's initial skill on the breast or bottle?

During early feeding, did your child display any of the following characteristics? arching, cry, spit up, gag, cough, vomit or pull off the nipple? List and describe any that apply.

Describe how the weaning process off the breast/bottle went and why the child was weaned?

What age was child introduced to baby cereal?

What age was child introduced to finger foods?

What age was child introduced to baby food?

What age was child introduced to table foods?

What age did child fully transition to table foods?

describe any difficulties child had with any of these transitions?

IF YOUR CHILD EATS BY MOUTH, PLEASE ANSWER THE FOLLOWING

List any foods your child will currently eat or drink?

Child's favorite foods

List any child food allergies?

Describe child's eating habits

Who typically feeds child?

How long is a typical meal?

Who typically eats with child?

Utensils or special cups/bowls used?

Type of chair used when child eats?

Other activities happening during meals?

Describe your child's eating schedule in the following format: (time // breast or bottle // type of food) list each time of day they typically eat.

IF YOUR CHILD EATS BY TUBE, PLEASE ANSWER THE FOLLOWING

Type of formula used and how is it mixed?

Where is child tube fed and what other activities are going on during that time?

Describe your child's reactions to tube feeding?

Describe your child's eating schedule in the folling format: (time // NG, G or Continuous // Amount // Gravity or Pump // Period of time or what rate) list each time of day they typically eat

PLEASE ANSWER FOR ALL CHILDREN

Describe any special diets aside from ones already described above

Describe how you know if your child is hungry and when they're full?

Explain any significant weight loss or gain in last 6 months?

List one of the following descriptions for your child's weight (ideal, underweight, overweight).

Describe any of the folowing problems if applicable (dental, constipation, diarrhea, vomiting, choking, gagging, coughing).

List any vitamin supplements your child takes?

Describe how you and your child feel after feeding?

Have any other evaluations been completed on your child and describe the results you were told?

Have any treatments been tried for any of the conditions explained above? Please describe treatment and results.

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

Additional Comments

SIGNATURE

By checking this box and signing below, I agree to the terms listed within this form. I confirm that I am the authorized parent/legal guardian for the child as detailed within this form.

Your Signature

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