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Feeding History Questionnaire

Questions?

Gabrielle Perelmuter, MOT OTR/L
Clinical Director & Occupational Therapist

(415) 531-3027
gp@littlehandsot.com

Little Hands
500 Tamal Plaza, Suite 505
Corte Madera, CA 9492
littlehandsot.com

Person Completing This Form

Full Name *

Date: * +

Relationship to Child *

Phone Number *

Email Address *

Child's Information

Child's Full Name *

Child's Date of Birth * +

Current Diagnoses: *

Medications: *

List the foods your child is allergic to: *

+-

Pediatric Feeding History Form

Please explain, in your own words, what your child's current feeding problem is: *

Was your child breast fed? *

Yes

No

If yes, from when to when:

Was your child bottle fed? *

Yes

No

If yes, from when to when:

Please describe your child's initial skill on the breast and/or bottle: *

During these early feedings, did your child frequently (please check all that apply): *

Please describe when they would happen, why, and for how long: *

Describe how the weaning process off the bottle and/or breast went and why the child was weaned: *

At what age was your child introduced to:

Baby cereal? *

Baby food? *

Finger foods? *

Table foods? *

When did they transition fully to table food? *

Please describe how these transitions were handled by your child, especially if any difficulties happened: *

List all the foods that your child currently will eat or drink:

+-

List the foods your child refuses:

+-

Describe your child's mealtimes:

Who typically feeds your child? *

Who typically eats with your child? *

What type of chair is used? *

How long are meals typically? *

Does your child use utensils or any type of special cups/bowls (describe): *

Are there any other activities going on at meals? What activities (describe): *

What times does your child typically eat meals or snacks?

	Time	Meal/Snack
1.)	Time	Meal/Snack
2.)	Time	Meal/Snack
3.)	Time	Meal/Snack
4.)	Time	Meal/Snack
5.)	Time	Meal/Snack
6.)	Time	Meal/Snack
7.)	Time	Meal/Snack
8.)	Time	Meal/Snack
9.)	Time	Meal/Snack
10.)	Time	Meal/Snack

How do you know if your child is hungry or full?

Hungry? *

Full? *

Has your child lost or gained any weight in the last 6 months, and how much? *

Would you describe your child's weight as: *

Ideal

Underweight

Overweight

Does your child have/had any of the following problems: *

Please describe:

Does your child take a vitamin supplement? Which one? *

Describe how you and your child feel after a feeding:

You: *

Your child: *

What other evaluations have you completed regarding your child's feeding difficulties and what were the results/what were you told? *

What treatments have been tried for this problem and what were the results? *

How can we be most helpful to you and your child? *

Document Library (Download/Acknowledge)

Please download, read, and accept the Little Hands Practices & Policies and the Notice of Privacy Practices. (Required for services)

1) Practices & Policies: Download our Practices & Policies here (PDF).

I acknowledge that I have downloaded, read and accept the Practices & Policies

*

2) Notice of Privacy Practices: Download our Notice of Privacy Practices here (PDF).

I acknowledge that I have downloaded, read and accept the Notice of Privacy Practices

*

Credit Card Authorization

Please complete the credit card authorization form. Credit cards are only charged in instances of overdue payment.

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

Security Number *

Street Address *

Address Line 2

City *

State *

Zip Code *

Credit Card Authorization *

I authorize Little Hands Occupational Therapy, Inc. to charge this credit card for late payments on invoices due and payments associated with any documentation, report writing and/or consultation which have not yet been paid in due time according to the practices and policies; as well as occupational and speech evaluations prior to the date of service.

Completion

I certify that the information I have provided above is accurate to the best of my knowledge. *

clear