Pediatric Feeding Questionnaire

Pediatric Feeding Questionnaire

Background Information
Child's Name*

First NameLast Name
Child's Age
Was your child carried to term?*

YesNo
How many weeks?*
Complications during pregnancy or birth?
Birth Weight (lbs):
Did your child require an extended hospital stay?

YesNo
If so, how long?
Early feeding history/difficulties:

	Yes	No
Breast fed
Bottle fed

If yes, for how long?
Any difficulties transitioning from breast to bottle?
Any difficulties transitioning from bottle to food?
Age of transition to solid foods:
Tolerance:

GoodFairPoor
Describe:
Age that feeding initially became a concern:
Has your child been seen by another specialist?

YesNo
If so, who?
Has your child ever received a Videofluoroscopic Swallow Study (VFSS)?

YesNo
If yes, when?
Results:
Previous evaluation results:
Does your child have any medical conditions or diagnoses?