Feeding Therapy Screening Form
Child's date of birth
Name of person completing this form
Does your child exhibit any of the following?
Does Not Chew
Does Not Feed Self
Does Not Eat an Age Appropriate Volume
Eats Small Amounts Throughout the Day (Grazing)
Only Eats Certain Textures/Colors/Brands
Takes too Long to Eat a Meal
Elimination of Foods That Were Previously Eaten Consistently
Puts too Much Food in Mouth at One Time
Does your child consistently eat at least 3:
Do any of the following behaviors occur when you give your child new or less preferred foods?
Throws Food or Utensils
Spits Food Out
Cries, Screams, Protests
Leaves the Table Before Finished
Takes Food From Others
Refuses to Eat until Preferred Foods are Given
Pushes Food Away
Has a physician or speech therapist indicated that your child should not be fed by mouth?
Does your child have a history of any of the items below?
Gastroesophageal Reflux Disease (GERD)
Failure to Thrive
Failure to thrive
Avoidant Restrictive Food Intake Disorder
Does your child receive tube feedings?
Yes. All daily nutrition is delivered via tube feedings.
Yes. My child's oral feedings are supplemented with tube feedings.
Is your child followed by any of the following service providers?
Nutritionist or Dietician
Occupational Therapist (related to feeding)
Speech Therapist (related to feeding)
Please list any diet restrictions that your child may have.
Who will be involved in caregiver training appointments?
How did you hear about us?
Is there anything else that you would like us to know about your child's mealtime behavior?
Send me a copy of my responses.
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