310 Baker Ave, Concord, MA 01742
Fax: 978-287-8240 Phone: 978-287-8200
133 Littleton Road, Suite 315, Westford, MA 01886
Fax: 978-589-6853 Phone: 978-589-6850
FEEDING CLINIC INTAKE FORM
DEMOGRAPHIC & FAMILY INFORMATION
Child’s Name: ______________________________
Date of Birth: __________________
Parent’s Name:
Nickname: ______________________________
Age: __________
Male _____
Female _____
Mother ___________________________
Father ____________________________
Address: _____________________________________________________________________________
Telephone Number: ______________________________
Cell: ____________________________
Pediatrician: ____________________________________
Insurance: _______________________
Siblings:
Date of Birth:
___________________________________
___________________________
___________________________________
___________________________
___________________________________
___________________________
___________________________________
___________________________
___________________________________
___________________________
Have any siblings ever received PT, OT, or Speech Therapy?
Yes _____
No_____
If yes, please explain: ___________________________________________________________________
_____________________________________________________________________________________
Do any family members have speech, language, hearing, feeding, swallowing, learning, or physical
development problems?
Yes _____
No_____
If yes, please explain: ___________________________________________________________________
SOCIAL/EDUCATIONAL
Child’s School __________________________________________
Grade/Level __________
If not school age, other group experience? _____________________________________________
How does your child play?
□ prefers to play alone
□ prefers to play with 1 or 2 others
□ plays mostly with siblings
□ plays mostly with adults
□ has a lot of friends
Is your child able to pay attention as well as most other children his/her age? Yes _____ No _____
BIRTH HISTORY
Normal pregnancy and delivery: Yes______
No _____
If no, please describe: ___________________________________________________________________
_____________________________________________________________________________________
MEDICAL INFORMATION
Any history of vomiting, spit up or gastroesophageal reflux?
Yes _____
No_____
Current medications for reflux: _________________________________
Are there concerns with weight gain or growth?
Yes _____
No_____
Most recent weight: _____
Date of recent weight: _____
Are there issues with constipation?
Yes _____
No_____
Current medications for constipation: ____________________________
Does your child have any food allergies or intolerances?
Yes _____
No_____
List all food allergies/sensitivities/intolerances: ______________________________________________
AREAS OF CONCERN/GOALS
When did you first have concerns about your child’s eating? ___________________________________
_____________________________________________________________________________________
What made you concerned? _____________________________________________________________
_____________________________________________________________________________________
Please check any techniques you have used to get your child to eat. Please circle the technique(s) that
is most effective.
□ Threaten
□ Coax
□ Offer reward
□ Send to time-out
□ Forced feeding
□ Distract with play/toys
□ Change meal schedule
□ Model
□ Praise
□ Use TV/video/iPad
□ Offer small meals
□ Ignore
□ Limit foods
□ Change food offered
□ Other: _______________________
Please check any behaviors that are of concern to you. Please circle the behavior(s) most concerning
to you.
□ Eats too fast
□ Eats too much
□ Refuses to open mouth
□ Spits food out
□ Turns away from food
□ Refuses to swallow food
□ Picky eater
□ Eats non-food items
□ Uses a bottle
□ Holds food in mouth
□ Reflux
□ Eats too little
□ Fails to chew food
□ Gags
□ Sneaks or steals food
□ Vomits
□ Drools
□ Messy eater
□ Leaves table
□ Food spills from mouth
□ Ruminates
□ Eats too slow
□ Pushes food away
□ Fails to suck
□ Throws or drops food
□ Cries or tantrums
□ Plays with food
□ Overstuffs mouth
□ Other: _______________________
What are your goals for therapy? (check all that apply)
□ Increase amount of food
□ Increase variety of foods
□ Improve mealtime behaviors
□ Increased weight gain
□ Decrease/eliminate tube feeds
□ Increase textures of foods
□ Improve oral motor skills
□ Decrease gagging during eating
□ Learn to use utensils
□ Other: __________________
FEEDING, EATING & SWALLOWING HISTORY
How is your child currently being fed? (check all that apply)
□ Mouth □ G-tube □ J-tube □ NG-tube □ NJ-tube
How does your child let you know he/she is hungry? __________________________________________
Who usually feeds your child? ____________________________________________________________
Where is your child usually fed?
□ lap □ infant seat □ table/chair □ high chair □ booster seat □ floor □ couch □ stand/roam
□ other: __________________
How much time does it take for your child to complete an average meal? ___________
Any problems (current or past) with: (please describe)
□ Breast feeding (latch/seal, suck)_________________________________________________________
□ Bottle feeding (latch/seal, suck) _________________________________________________________
□ Sippy cup or straw drinking (liquid loss)___________________________________________________
□ Spoon-feeding (purees, yogurt, etc)______________________________________________________
□ Chewing (soft solids, crunchy solids, table foods)____________________________________________
How would you describe the variety of food in your child’s oral diet:
□ Extremely picky □ Moderately picky □ Mildly picky □ No concern
Does your child cough or choke when drinking or eating?
□ Yes, with liquids □ Yes, with solids □ No coughing or choking
Please check the box that describes your child’s current intake of each of the following food types:
Consistency
Does eat Can eat Cannot eat Won’t eat Never tried Comments
Regular liquid
Thick liquid
Stage 1 or 2 baby food
Food prepared in blender
Ground or stage 3 baby food
Mashed table food
Chopped table food
Regular table food
Crisp food (crackers)
Chewy food (meat)
Crunchy food (carrot)
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Indicate your child’s temperature and taste preferences:
Item
Likes
Dislikes
No Preference
Hot food
Cold food
Room temperature
Salty food
Spicy food
Sour food
Sweet food
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What does your child eat on a “typical” day? List specific foods and times
Morning _____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Noon ________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Evening ______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Overnight ____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Any additional information or concerns you would like us to know to help us understand your child’s
feeding/swallowing skills:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
SENSORY MOTOR SKILLS
Please check any statements that describe your child
_____ Frequently trips on his/her own feet
_____ Walks on his/her toes
_____ Frequently bumps into furniture, walls, or other people
_____ Unaware of being touched or bumped unless done with extreme force
_____ Unaware of that face or hands are dirty (i.e., nose running, food on face)
_____ Seems unsure of how to move his/her body; is clumsy and awkward
_____ Slumps or slouches when sitting; places head on hand when sitting
_____ Has difficulty learning new motor tasks
_____ Is in constant motion
_____ Has difficulty sitting still
_____ Chews on pens, straws, shirts, etc
_____ Frequently touches people and objects
_____ Frequently gets in everyone else’s space
_____ Is overly sensitive to touch, noise, smells, etc
_____ Avoids touching certain textures (please list: _______________________________________)
_____ Avoids messy play (i.e., finger paints, playdough, mud, sand)
_____ Only eats certain foods or food textures (please list:__________________________________)
_____ Is sensitive to clothing tags or textures
_____ Complains about having hair brushed
_____ Resists having teeth brushed
_____ Does not like to have fingernails trimmed
_____ Refuses to walk barefoot
_____ Has trouble falling asleep or staying asleep
_____ Gets “stuck” on toy or task and has difficulty changing to another task
_____ Is fearful on swings
_____ Is fearful of slide or other playground structures
_____ Is fearless on playground equipment
Comments about your child’s sensory or motor skills that might help us better understand your child:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________