PATIENT IDENTIFICATION
Comprehensive Pediatric Feeding and Swallowing Program
Intake Form
Please take some time to complete this form to give us general information about your child’s feeding history. Feel free to
write any comments that you think may be helpful to us in evaluating your child.
Child’s Name____________________________________Birth date: ______________Date Form Completed___________
Others living in the home, and relationship:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
Names of other doctors outside of NCH involved with your child:
q Cardiology _______________________ q Psychology______________________ q Other___________
q GI _______________________________ q Pulmonary ______________________
q Nutrition _________________________ q Allergy __________________________
q ENT ______________________________ q Neurology ______________________
I. Particular Needs
Cultural considerations:
Do you speak English? q Yes q No Do you need an interpreter? q Yes q No
Ethnic Background: __________________________________________________________________________________
Are there any cultural or religious practices regarding food or affecting how we care for your child?
q Yes q No
If so, describe: _____________________________________________________________________________________
II. Feeding Problems:
What problems is your child now having? (Check as many problems as your child has)
q Will not eat enough food by mouth
q Refuses to eat certain kinds of food (smooth, lumpy, crunchy, spicy) Describe: _______________________________
_________________________________________________________________________________________________
OCC-408 Comprehensive Pediatric Feeding and Swallowing Program Intake Form 01/09; Revised 12/3/20 Page 1 of 3
q Seems to have problems taking liquids. Describe _______________________________________________________
_________________________________________________________________________________________________
q Seems to have difficulty with solid foods. Describe: _____________________________________________________
_________________________________________________________________________________________________
q Seems to have difficulty with temperature of food or liquids (too hot or too cold)
q Other: ________________________________________________________________________________________
When did you first notice feeding problems? _____________________________________________________________
Does your child have any oral restrictions? _______________________________________________________________
What do you think caused these feeding problems? ________________________________________________________
_________________________________________________________________________________________________
What is your goal for the Feeding Evaluation Clinic Visit? ____________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
III. Medical History
Therapy Programs and School:
Does your child receive therapy? How often? Where? For Feeding?
q Occupational Therapy ___________________ _________________ _____________
q Physical Therapy ___________________ _________________ _____________
q Speech Therapy ___________________ _________________ _____________
q Other therapy _________________________________________________________
IV. Review of Issues
Type of feed Past Present/Current
q NG (nasogastric tube feeds)
______________________
_________________________________
q OG (oral gavage feeds)
______________________
_________________________________
q NJ (nasojejunal feeds)
______________________
_________________________________
q GT (gastrostomy tube feeds)
______________________
_________________________________
q TPN (total parental nutrition)
______________________
_________________________________
q JT (jejunal feeds)
______________________
_________________________________
OCC-408 Comprehensive Pediatric Feeding and Swallowing Program Intake Form 01/09; Revised 12/3/20 Page 2 of 3
On average, how many ounces does your child drink a day? _________________ ounces
What liquids does your child now take?
Milk___________ ounces per day
Formula________ ounces per day Which Formula? ____________
How many meals/snacks does your child usually eat in a day? ______meals _____snacks
Food my child likes Foods my child dislikes
OCC-408 Comprehensive Pediatric Feeding and Swallowing Program Intake Form 01/09; Revised 12/3/20 Page 3 of 3
