TOTS Case History

First Name

Last Name

Date of Birth

Address

Home Phone

Cell Phone

Referring Physician

Date of Physician Report

Birth History

Were there any complications during pregnancy

Yes No

Did you carry your baby full term?

Yes No

Were there problems during delivery?

Yes No

Did your baby require any special care after delivery?

Yes No

Birth Weight

Percentile Birth Weight

Length/height

Percentile of length/height

Apgar Score

MEDICAL HISTORY

Does your child have a medical or educational diagnosis?

Yes No

Has your child ever been on medication?

Yes No

Is your child currently on medication?

Yes No

DENTAL HISTORY

Has your child been seen by a dentist?

Yes No

Was your baby breast- or bottle-fed?

Breast fed Bottle fed

How did you originally plan to feed your baby?

Are there any concerns about nutritional status?

Yes No

Do you have any concerns about feeding safety?

Yes No

Has your child had a swallow study? (If so please attach the results)

Yes No

Did you seek assistance with breastfeeding?

PCP

Lactation Consultant (IBCLC)

SLP

Was a lip-tie or tongue-tie identified?

Yes No

Were you encouraged to see/discouraged from seeing a specialist?

Yes No

Did you child have any difficulty breastfeeding/bottle-feeding (if yes, please check all that apply below)

Difficulty latching

Coughing

Crying

Reflux

Gagging

Dribbling

If other, please specify

At what age did you introduce spoon-feeding?

Did your child have any difficulty with smooth pureed food? (if yes, please check all the apply below)

Yes No

If yes, please check all that apply

Coughing

Vomiting

Gagging

Spitting out food

Choking

Food Refusal

Other

Did your child have any difficulty with chunky pureed food? (if yes, please check all the apply below)

Yes No

If yes, please check all that apply

Coughing

Vomiting

Gagging

Spitting out food

Choking

Food Refusal

Other

At what age did you introduce solid foods?

Did your child have any difficulty with dissolvable solids (ex., Cheerios, Puffs) (if yes, please check all the apply below)

Yes No

If yes please specify

Coughing

Vomiting

Gagging

Spitting out food

Choking

Food Refusal

Other

Did your child have any difficulty with soft vegetables/fruits? (if yes, please check all the apply below)

Yes No

If yes please specify

Coughing

Vomiting

Gagging

Spitting out food

Choking

Food Refusal

Other

At what age did your child stop breast- or bottle-feeding?

Did your child have difficult transitioning to a straw?

Yes No

Did your child have difficulty transitioning to a cup?

Yes No

Is your child on a special or restricted diet (e.g., glute-free, dairyfree) (If yes, please describe below)

Yes No

If yes, please specify

Does your child have a self-limited diet? (e.g., gluten-free, dairyfree) (if yes, please describe below)

Yes No

If yes please specify

Does your child have food aversions? Please indicate difficulties with taste, texture, temperature, color, size and/or shape

Yes No

If yes please specify

Are mealtimes longer than normal?

Yes No

Would your child prefer to graze rather sit for a meal?

Yes No

Five Day Baseline Diet

Please chart what your child eats (item and amount) in the following Five-Day Baseline Diet:

DAY 1: Breakfast, Snack, Lunch, Snack, Dinner, Snack

DAY 2: Breakfast, Snack, Lunch, Snack, Dinner, Snack

DAY 3: Breakfast, Snack, Lunch, Snack, Dinner, Snack

DAY 4: Breakfast, Snack, Lunch, Snack, Dinner, Snack

DAY 5: Breakfast, Snack, Lunch, Snack, Dinner, Snack

ORAL MOTOR HABITS

Has your child had excessive drooling?

Yes No

Does your child suck his/her thumb or digits?

Yes No

Did your child use a pacifier? (if yes, enter how long below

Yes No

Does your child exhibit open-mouth posture and mouth breathing?

Yes No

Is your child’s speech intelligible to the familiar listener?

< 25% 25-50% 50-75% > 75%

Is your child’s speech intelligible to the unfamiliar listener?

< 25% 25-50% 50-75% > 75%

Does intelligibility change as your child moves from single words to sentences?

Do you have any concerns about sound production? (If yes, what sound(s) does your child have difficulty producing (circle sounds that apply)

Yes No

THERAPY

Has your child been seen a lactation specialist? If yes, please provide name below

Yes No

Has your child been seen for feeding therapy (If yes, please provide name of treating therapist below

Yes No

Has your child been seen for speech therapy? (If yes, please provide name of treating therapist below)

Yes No

Additional Information (Feel free to use the back of this form.)

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