Food Inventory Form

Patient Name

Date of Birth

Check off all of the foods your child currently eats. Feel free to list specific brand names of food items if your child has a preference.

Texture Preferences:

Crunchy

Crisp

Smooth

Lumpy

Uniform lumpy (i.e., cottage cheese)

Hard

Chewy

Mixed consistencies

Taste Preferences:

Salty

Sweet

Spicy

Tart/Sour

Bland

Temperature Preferences:

Hot

Warm

Cool

Cold

Please explain any of the above.

Please list meat choices here.

Eggs (mark all that apply):

Scrambled

Omelet

Fried

Hard boiled

Soft boiled

Poached

With cheese, vegetables, salsa, chopped meats, etc.

Please list other salad dressings and any other condiments here.

Please list bell pepper color, baby food vegetables and other vegetables here.

Please list melon types and fruit baby foods here.

Cheese/Yogurt:

Cheese - list type(s) below

Cottage cheese

Yogurt - list type(s) below

Please list types of cheese and yogurt here.

Please list types of dry cereal.

Pasta/Noodles:

Macaroni and cheese

SpaghettiOs/RavioliOs

Pizza

Pizza toppings (list below)

Mixed pasta dishes (i.e. spaghetti/lasagna)

Mixed rice dishes

Mixed noodles dishes

Please list pizza toppings here. Please describe mixed pasta/rice/noodle dishes.

Please list other soups here.

Please list types, other liquids here.

Please list types here.

Fast Foods:

Allergies:

Gluten

Egg

Dairy

Soy

Fish/shellfish

Nuts

Other (list below)

Please list other allergies here.

We also analyze favorite and least-favorite foods for patterns and similarities. Please list your child’s favorite foods/liquids:

Please list your child’s least-favorite foods/liquids:

What goal foods would you like to see your child eat with the rest of the family?

Appetite:

Best time of day to eat:

Overall description of appetite:

Poor Fair Good Varies from day to day

Selective Eating Age of Onset:

Is your child taking any medications (please list)?

Other comments:

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