Feeding Intake Form Child's Name * First Name Last Name Does you child have any of the following proglems? Please check all that apply Food refusal (refusing all or most food) Food selectivity by texture (eating only textures that are not developmentally appropriately) Limited variety of foods consumed Oral motor delays (problems with chewing, lip closure, or tongue lateralization) Dysphagia (problems with swallowing) Abnormal preferences (refuses food if not a certain temperature, only eats certain brands, must have certain silverware or cup to eat/drink) What issues are you trying to resolve Check as many as apply Increase the volume of food my child eats Increase the variety of foods my child eats Improve oral motor skills Decrease gagging during eating Reduce/eliminate diarrhea Increase weight gain Resolve reflux or other GI issues Increase the texture of food my child eats Improve cup drinking Improve mealtime behaviors Decrease vomiting related to eating Reduce/eliminate constipation Decrease tube feedings Other feeding problems (please describe) How many ounces does your child drink per day? Was feeding interrupted at any time in the child's history? Please state yes/no. If yes please state how long and for what reason. Where does your child eat? check all that apply Caregiver's lap High chair Booster seat Chair at the table Infant seat Other Does the child have any of these issues at mealtimes? check all that apply Throws food during meal Spits out food Cries and screams at meal Leaves the table before finished Messy eater Takes food from others Refuses to self-feed Overeats How many times per week do the above events occur? Describe a typical meal in detail Appetite is described as? Poor Fair Good Excellent How long does it take for the child to complete at meal? Less than 10 min 10-20 min 20-30 min 30-60 min over 60 min How does your child indicate hunger? Does your child currently have, or has your child had, any of the following issues? Autism Developmental or Speech Delay ADHD Learning disability Intellectual disability Traumatic brain injury Depression Bipolar disorder Anxiety disorder or OCD Cerebal palsy Spina bifida Seizure disorder Diabetes Prematurity Gastroesophageal reflux Chronic constipation Chronic diarrhea Food allergies Lactose intolerance Seasonal allergies Blind or severe vision impairment Deaf or severe hearing impairment Delayed gastric emptying G-tube or NG tube feeding Liver disease Endocrine disorder or problems with growth Heart problems Current feeding skills check all that apply Drinks from bottle Held by caregiver Child holds bottle Feeds self with fingers Feeds self with spoon Feeds self with fork Drinks from open cup/glass Dairy - Likes Please check all that your child WILL consume. Nonfat milk Whole milk 1% milk 2% milk Chocolate milk Strawberry milk Soy milk Nonfat yogurt low fat yogurt Greek yogurt Cottage cheese Ice cream Frozen yogurt Cheese Other dairy preferences Protein - LIkes Please check all that your child WILL eat Beef Chicken Turkey Fish Pork Ham Bacon Sausage Eggs Egg substitute Peanut Butter Almond butter Seafood Tuna fish Protein supplements Seeds Beans Nuts Other protein preferences Starch - Likes Please check all that your child WILL eat Bagel Pancakes Brown rice White rice English muffin Waffles Pasta White bread Wheat bread French toast Gluten-free Popcorn Pita bread Granola Sweet potato Pretzels Crackers Tortilla Flat bread French fries Dinner roll Taco shells Buns Muffin Sweet breads Masa Quinoa Cereal Chip Other starch preferences Fruits - Likes Please check all that your child WILL consume Apple Blueberries Peaches Guava Applesauce Cantaloupe Pears Jackfruit Banana Watermelon Strawberries Dates Orange Mango Fig Grapefruit Kiwi Prunes Honeydew Lemon Lime Cherry Papaya Plum Pineapple Dried fruit Tangerine Grapes Canned fruit Frozen fruit Other fruit preferences Vegetables - Likes Please check all that your child WILL consume Asparagus Cucumber Mushroom Iceberg lettuce Cauliflower Green beans Peppers Romaine lettuce Brocolli Brussel sprouts Cabbage Leafy lettuce Celery Onion Roasted vegetables Spinach Carrot Pumpkin Radish Leek Potato Sweet potato Corn Avocado Garlic Eggplant Squash Carrots Tomato Peas Jicama Other vegetable preferences Beverages - Likes Please select all that your child WILL consume Water Soda Diet Soda Caffeine-free Vegetable juice Fruit juice Sport drinks Crystal light coffee Tea Energy drinks Ensure/Boost/Pediasure Coconut water Carbonated drinks Smoothies Other beverage preferences Condiments and dressings - likes Please check all that your child WILL consume Butter Creamy salad dressing salsa Guacamole Margarine Oil-based dressing Lard Hummus Cream cheese Tomato sauce Sour cream Soy-based Jelly/jam Syrup Relish Ketchup Mustard BBQ sauce Savory Sweet Spicy Olive oil Other condiment preferences What foods will your child eat for breakfast? Please check all that your child WILL consume Cereal Oatmeal English muffin Bagel Muffins Danish/Donuts Home fries/hashbrowns Eggs Bacon Sausage Ham Toast Waffles Pancakes French Toast Pediasure Cereal bar Milk Water Breakfast drink What foods will your child eat for lunch Pasta with butter Pasta with cheese Pasta with tomato sauce Nachos Chili Pizza Hot dogs Hamburgers Chicken nuggets Fish Bologna Soups Sandwich (deli) Grilled cheese PB&J Peanut butter French Fries Potato salad Coleslaw Pretzels Chips Cookies Crackers Fruit roll-up Pineapple Yogurt Pudding Jello Fruits Vegetables What foods will your child eat for dinner Please check all that your child WILL consume Steak Roast beef Pork roast Lamb Hotdogs Hamburgers Ground beef Chicken Chicken Nuggets Fish Nachos Soups Pasta with butter Pasta with cheese Lasagna Rice Couscous Beans French fries Mashed potatoes Baked poatoes Tator tots Cheese Fruits Vegetables Cookies Cake Pie Pudding Ice cream Thank you!
