Feeding & Nutrition Intake Questionnaire

Child's Name

Date of Birth

The goal of this questionnaire is to gain information about your child's feeding history in order to help us design the most effective treatment plan for your family. Please be as specific as you can, and add any other details you'd like us to know!

What are your primary concerns about your child's feeding or nutrition?

MEDICAL & DEVELOPMENTAL HISTORY

Does your child have any food allergies?

Dairy

Egg

Soy

Nut

Gluten

Other

Other food allergies or sensitivities:

Does your child have a history of:

Constipation

Diarrhea

Reflux

Frequent colds

Gastrointestinal problems

Excessive vomiting

Was your child breast-fed or bottle-fed?

Breast-fed Bottle-fed formula Bottle-fed breast milk

What type of formula did your child drink?

As an infant, did your child have difficulty with any of the following?

Latching to breast/bottle

Transitioning from breast to bottle

Transitioning to pureed foods

Transitioning to hard solid foods

Decreased chewing (whole foods in stool)

At what age did you introduce baby foods?

Can your child....

Eat table foods?

Yes No

Use a fork/spoon?

Yes No

Drink from an open cup?

Yes No

Drink from a straw?

Yes No

What type of cup does your child currently use?

Bottle Sippy Cup Open Cup Cup with Straw

Does your child do any of the following? Please check all that apply.

Takes small bites

Overstuffs mouth

Chokes or coughs while eating

Gags at mealtimes

Has difficulty chewing

Puts non-food items in mouth

CURRENT FEEDING HABITS

Describe your family's current mealtime routine:

How many meals does your child eat in a day?

How long does your child typically sit for a meal?

Does your family eat meals together?

Always Often Sometimes Rarely Never

Does your child eat the same meals as your family?

Always Often Sometimes Rarely Never

Where does your child sit during meals?

High chair

Regular chair

Wanders

Caregiver's lap

Car seat

Stands up

Sofa

Who usually feeds/eats with your child?

Photo of your child sitting in their usual seat for a meal:

Add file

Please upload a file

Does your child do any of the following during meals?

Refuses to eat

Tries to get out of seat

Spits out food

Cries/screams

Throws food/utensils

Holds food in mouth

At which meal does your child eat the most?

Breakfast Lunch Dinner Snacks Varies

Does your child feed him/herself?

Yes No

Finger feeding:

Independent Partially Successful Does not attempt

Feeding self with utensils:

Independent Partially Successful Does not attempt

About how many different foods does your child eat?

If less than 20, please list ALL of the foods your child eats.

Please be specific: brands, flavors, preparation methods

Please list a few examples of foods your child will eat from each food group.

Fruits

Vegetables

Grains (bread/cereal/pasta/rice)

Proteins (meat/eggs/nuts)

Dairy (milk, yogurt, cheese)

Other (snack foods)

YOUR CHILD'S PREFERENCES

Texture Preferences

Crunchy

Chewy

Hard

Soft

Lumpy

Smooth

Mixed textures

Uniform consistency

Taste Preferences

Salty

Flavored

Sweet

Bland

Spicy

Tart

Temperature Preferences

Hot

Warm

Cold

Room Temp

Appetite

Poor

Fair

Good

Varies

What are your child's five FAVORITE foods/liquids?

What are five of your child's LEAST favorite foods/liquids?

How does your child behave when presented with a least favorite food on his/her plate?

What are five GOAL foods you'd like your child to eat?

Please share any other information you think might help us understand more about your child's feeding history and your current concerns about your child's feeding.

Name of person completing this form

Relationship to child

Email address

Phone Number

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