Paediatric Feeding History Form Please complete and submit before assessment. Your Contact Email (required) Contact Person (required) Child's name Child's Date of Birth Parent Date 1. Please explain, in your own words, what your child’s current feeding problem is: 2. Was your child breast fed? From when to when? 3. Was your child bottle fed? From when to when? 4. Please describe your child’s initial skill on the breast and/or bottle: 5. During these early feeding, did your child frequently arch, cry, spit up, gag, cough, vomit or pull off the nipple? If yes please describe when they would happen, why and for how long 6. Describe how the weaning process off the breast and/or bottle when and why the child was weaned 7. At what age was your child introduced to: Baby cereal Puree food Finger foods Table food 8. At what age did they transition fully to table food? 9. Please describe how these transitions were handled by your child, especially if any difficulties happened: 10. Describe your child’s mealtime: Who typically feeds your child? Who typically eats with your child? What type of chair is used? How long are the meals typically? Does your child use utensils or any type of special cups/bowls (describe)? Are there any other activities going on at meals (describe)? What times does your child usually eat? Breakfast Lunch Dinner Snacks 11. Is your child allergic to any foods? 12. Has your child ever been on ay type of special diet? If yes please describe type of diet, what ages, why and your child’s response 13. How do you know when your child is hungry or full? Hungry Full 14. Has your child lost or gained any weight in the last 6 months, and how much? 15. Would you describe your child’s weight as (tick one)? IdealUnderweightOverweight 16. Does your child have/had any of the following problems (tick all relevant and describe)? DentalFrequent constipationFrequent diarrheaVomitingChokingGaggingCoughing 17. Does your child take a vitamin supplement? Which one? 18. Describe how you and your child feel after a feeding: You Your child 19. What other evaluations have been completed regarding your child’s feeding difficulties and what were the results? 20. What treatments have been tried for this problem and what were the results? 21. What do you want to achieve from this assessment? How can we help you? List the foods that your child will currently eat and drink (put a star next to their favourites) List the foods your child refuses to eat
