Food and Mealtime Assessment
If you have concerns regarding your child's eating, please complete this form in addition to our New Patient Intake form. Please be as thorough as possible as this information will help the evaluating therapist prepare for your child's evaluation.
Sign in to Google to save your progress. Learn more
Child's Initials (ex: J.J) *
Phone number to reach you if we have questions about this form *
Name of the person completing this form and relationship to the child *
Please list the PROTEINS that your child consistently eats
Please list the CARBOHYDRATES that your child consistently eats
Please list the FRUITS/VEGETABLES that your child consistently eats
What are your primary concerns regarding your child's eating/feeding?
Please list any foods, tastes or textures, that your child will not eat
How does your child eat (check all that apply)?
Where does your child eat most meals?
Mealtime seating (check all that apply)
Distractions present during meals
Mealtime behaviors (check all that apply)
Please describe child's mealtime routine
Clear selection
Please describe your child's meal schedule including foods child typically eats for each meal or snack and approximate quantities.
Please check all that apply/occur during FOOD or LIQUID intake
Typical length of meals
Is child's weight appropriate for age and height?
Clear selection
Please note any additional information or comments you would like the evaluating therapist to know
NOTE: For feeding evaluations, we ask that you bring your child hungry, bring 2 preferred and 2 non preferred foods to the evaluation. *
NOTE: This form MUST be accompanied by our New Patient Intake Form, which is required for new intakes. The intake form can be completed online on our website. Please select the appropriate response *
Submit
Clear form
Never submit passwords through Google Forms.
GoogleForms
This form was created inside of The Therapy Spot.