Therapy OPS Feeding Intake
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Diagnosis (of any kind)
*
Present Weight
*
Present Height
*
Reason for evaluation
*
Recommendation from other professional(s): What concerns were shared with you and by whom?
*
Please list any medical precautions or special diet instructions for your child: (ie: gluten casein free diet)
*
Are there any cultural or religious practices regarding food or affecting how we care for your child? If yes, please describe:
*
Has there been any recent (past 12 months) or ongoing stressors at home/with family that would impact your child's feeding issues (ie. martial divorce, death in family, school problems, medical problems, ect.)?
*
Please list any additional evaluations and therapy that has been completed regarding your child's feeding difficulties and the results.
*
Medical History
Does your child have any allergies?
*
Seasonal
Food
Medications
Other
Please list specific allergies as noted above
*
Medication: Please list all medications, over the counter products, supplements and natural/herbal remedies your child currently takes. For each one, please list name, dose, how often and reason for taking.
*
Has your child ever been hospitalized or had procedures/tests completed?
*
Yes
No
If yes, please list the date, reason and location:
*
Has your child had a swallow study completed
*
Yes
No
If yes, please list when, where, reason for completing and results.
*
Has your child ever needed:
*
Gastrostomy Tube Feeding
Jejunostomy Tube Feeding
Other not listed
No Tube Feedings
If yes, when was it started and stopped?
*
Nutritional History
Was your child:
*
Breastfed
Bottle-fed
Breastfed or Bottle-fed from When-When
*
Please describe your child's initial skill on the breast and/or bottle. Were there any problems?
*
During these early feedings, did your child frequently arch, cry, spit up, gag, cough, vomit or pull off the nipple? Write which ones and describe when they would happen, why and for how long.
*
Does your child have reflux?
*
Yes
No
If yes, has your child taken medication for symptoms? If so, please list medication, dosage and for how long?
*
At what age did your child transition to baby foods?
*
At what age did your child transition to solid foods?
*
Please describe how your child tolerated these changes. Were there any problems?
*
Review of Issues:
Feeding Behaviors: Please check all that apply regarding feeding
*
Gagging
Coughing
Choking
Vomiting during feeding
Vomiting after feeding
Holds food in mouth
Poor appetite
Frequent diarrhea
Frequent constipation
Dental concerns
Gets tired easily
Eating time is stressful for child/parent
Leaves the table
Cries during feeding
Tantrums
Spits food out
Loses lots of food when chewing
Other
How do you know your child is hungry or full?
*
Would you describe your child's weigh as:
*
Ideal
Underweight
Overweight
Has your child lost or gained any weight in the last 6 months? If yes, how much?
*
Household Needs/Environment
What foods would you like to see your child eat with the rest of the family?
*
What time of day does your child eat best?
*
Who typically feeds/eats with your child?
*
What type of chair is used?
*
How long are meals typically?
*
Are there any activities going on at meals (ie. music, TV)?
*
List child's favorite foods
*
List child's non-preferred foods
*
To help us identify your child's food preferences/oral skills, please check the appropriate boxes for the food below:
Rows
Eats consistently
Has tried/tasted (inconsistent)
Have offered (refused)
Has not been offered
Chicken Strips
Chicken Nuggets
Baked Chicken
Grilled Chicken
Fried Chicken
Turkey
Ham
Bacon
Turkey Bacon
Bologna
Pepperoni
Sausage
Hamburger
Turkey Burger
Veggie Burger
Roast Beef
Lunch Meat
Nuts
Eggs
Tofu
Meatballs
Black Beans
Kidney Beans
White Beans
String cheese
Cottage cheese
Cheese slices
Beef jerky
Fried fish
Baked fish
Fish sticks
Tuna
Salmon
Veal
Pork
Steak
Ribs
Roast
Beef
Hot dogs
Corn dogs
Baby food meat
Peanut butter
Walnuts
Cashews
Almonds
Pecans
Sesame seeds
Sunflower seeds
Macadamia nuts
mixed nuts
STARCHES
Crackers (please list in section below)
Chips (please list in section below)
Pretzels (list below if rod, twist, stick, waffle)
Snack mix (list contents)
Bugles
Cheetos
Doritos
Goldfish crackers (list flavors)
Pringles (list flavors)
Nutrigrain bars
Pop tarts
Rice cakes
Rice puffs
Granola
Cereal (list types below)
Taco Shells (hard or soft below)
Bread (Indicate below if white, wheat, rye, potato, rice, gluten free, pumpernickel, toast, French bread, dinner rolls, hamburger/hotdog buns)
Pizza crust
Break sticks/garlic bread
Crescent rolls, croissants
Biscuits
Pancakes
Waffles
French toast
Bagels (list flavor below)
Doughnuts
Sweet rolls
Cinnamon rolls
Caramel rolls
Banana bread
Pumpkin bread
Apple bread
Muffins
Corn bread
Cake/cupcakes
Pies and other pastries (list below)
Cookies
French Fries
Tater tots
Hash browns
Fried potatoes
Baked potatoes
Potato wedges
Mashed potatoes
Scalloped potatoes
Sweet potatoes
Sweet potato fries/chips
Veggie chips/fries
Macaroni and cheese
Spaghetti
Lasagna
Rotini
Penne
Fettuccini
Ramen
Noodle shapes
Spaghettioh's
Ravioli
Bowties
Tortellini
Rice
Oatmeal
Cream of wheat
Grits
Couscous
FRUITS
Green apple
Red apple
Yellow apple
Apple slices
Apple chunks
Apple without peel
Bananas
Grapes
Fresh berries
Frozen berries
Blueberries
Strawberries
Raspberries
Black berries
Boysenberries
Cranberries
Melon slices
Melon balls
Honeydew
Cantaloupe
Watermelon
Mango
Guava
Papaya
Star fruit
Pineapple
Pomegranate
Orange
Tangerine
Lemon
Lime
Grapefruit
Peaches
Pears
Nectarines
Plums
Raisins/Craisins
Apricots
Dates
Prunes
Cherries
Kiwi
Rhubarb
Dried fruit (list types below)
VEGETABLES
Carrots cooked
Carrot sticks
Carrot slices
Carrot grated
Jicama
Yellow squash
Zucchini
Red peppers
Green peppers
Yellow peppers
Orange peppers
Pumpkin
Tomatoes
Black olives
Eggplant
Broccoli cooked
Broccoli raw
Peas cooked
Peas raw
Pickles
Cucumber
Celery
Avocado
Green beans cooked
Green beans raw
Spinach raw
Spinach cooked
Cauliflower
Squash
Lettuce
Coleslaw
Cabbage
Asparagus
Onion
Vegetable baby food
Other
PUREES/CONDIMENTS
Applesauce
Yogurt
Hummus
Salad dressing (list brand and flavor below)
Cream Cheese (list flavor below)
Whipped cream
Pudding (brand and flavor below)
Honey
Soup
Pie puree/filling
Peanut butter
Maple syrup
Easy cheese
Ketchup
Mustard Yellow
Mustard Dijon
Mustard Spicy
Mustard Honey
Spaghetti sauce
Pizza sauce
Guacamole
Salsa
Jello
Jelly/Jam
Mayo/Miracle whip
BBQ sauce
A1 steak sauce
Chili sauce
Worcestershire sauce
Butter/Margarine
Gravy
Chip dip
Ice cream (list brand and flavor below)
Sherbet
Sour cream
Other (list below)
LIQUIDS
1% cows milk
2% cows milk
Skim cows milk
Chocolate cows milk
Strawberry cows milk
Rice milk
Soy milk
Almond milk
Breakfast shakes
Supplements (Pediasure, Boost)
Juice (list kind below)
Lemondae
Pop/Soda
Tea
Milk shakes/Smoothies
Water
Koolaid
Crystal light
OTHER
Vegetable soup
Chili
Stew
Potato soup
Clam chowder
PREFERENCES
Crunchy
Crispy
Smooth
Lumpy
Hard
Chewy
Mixed consistencies
TASTES
Salty
Sweet
Spicy
Tart
Flavored
Bland
TEMPERATURE
Hot
Warm
Cold
Cool
SMELL
Low scent
Strong scent
Please list all indications noted from chart above:
*
Submit
Should be Empty: