Feeding Clinic Questionnaire

Feeding Clinic Questionnaire
Please complete this questionnaire prior to the consultation
Name
First NameLast Name
Date of Birth
DayMonthYear
Date
Age at Appointment
Age Category
Please indicate if
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Phone Number
Country CodeArea CodePhone Number
Email
example@example.com
Date of the Appointment
MonthDayYear
Date
Would you like a recording of the consultation?
Appointment
Referring Healthcare Professional
Email of Referring Healthcare Professional
example@example.com
Address of Referring Healthcare Professional

Reason for Referral
Food Refusal
Other
Feeding Difficulties
Other
Nutritional Assessment
Other
Gastrointestinal Symptoms
Other
Neurological and Developmental
Other
Food Allergies/Intolerances
Other
Enteral Feeding
Other
Other
What are your main feeding/eating concerns?

Medical History/Update
Born
Weeks
Please list your Child's current Diagnosis/es
Age of Presenting Symptoms (indicate months or years)
Description of Past Medical Symptoms
Medical Update since the Last Consultation
Current Medication
Nutritional Update since the Last Consultation
Please indicate any investigations and upload results where possible?
Other
Assessment of Medical Investigations
Relevant Reports for Investigations (please upload relevant results)
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Feeding History
Breastfeeding after Birth
If yes, until what age?
Do you recall any problems with breastfeeding?
Please describe this further
Formula (bottle)feeding
Please name the formula/s, sequence of use (where appropriate)
Do you recall any problems with bottle feeding?
Please describe this further?
Please give a brief description of breast/bottle feeding history?
Have solid foods been introduced?
At what age was solid food introduced?
Describe how your child accepted solids following initial introduction?
Did your child ever need to be on an elimination diet (i.e. cow's milk, egg)?
Describe the food elimination and sequence of elimination ?
Did your child have a problem with any of the following?
Is there anything else that you would like to share about your child's feeding history?

Clinical and Growth Assessment
Weight Measurement
Date of Measurement
DayMonthYear
Date
Weight in kg
Centile (if known)
Length/Height Measurement
Date
DayMonthYear
Date
Length/Height Measurement
Centile (if known)
BMI
Centile
Growth Charts (please upload photos of your child's growth chart)
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Growth Assessment
Other
Clinical Symptoms Observed
Description of Clinical Symptoms
Photos of Clinical Assessment
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Bowel Frequency
Bristol Stool Chart
Stool Characteristics
Other

Current Feeding
Please complete the following questions about your child's current feeding pattern
Does your child enjoy eating?
Are you anxious during mealtimes?
How long does a mealtime take?
Are any of the following currently present?
Other
Other Sensory Sensitivities
Is your child sensitive to any of the following (tick all that are applicable)
Other

Current Dietary Intake
Are any foods currently eliminated?
Which foods are currently eliminated?
Which food allergens have been introduced to date?
Other
Breastfeeding
Please describe Breastfeeding Frequency and Efficacy
Formula or Enteral Feed
Please specify the formula/feed, the frequency and volume
Provide a list of other fluids (i.e. water, juice) your child is drinking
Please describe the bottle and cups your child uses
Does your child cough regularly whilst eating and drinking?
Please describe this further?
Is there any history of lower respiratory tract infections/ bronchiolitis/ bronchitis/ aspiration pneumonia?
Please describe this further?

Food Diary
Please provide us with a description of your child's intake. You can enter multiple meals under each section if you wish.
How many meals does you child have per day?
Portion Sizes
Meal 1 (i.e. breakfast)
Meal 2 (i.e. lunch)
Meal 3 (i.e. dinner)
Calcium (bone nutrient) Rich Foods/Day
Iron Rich Food Sources/Day
Zinc Rich Foor Sources/Day
Omega-3-fatty Acid Sources/Week
Fruit/Vegetable Source/Day
Typical Snacks
Typical Treats and Frequency of Receiving these Treat
Vitamin and Mineral Supplements for Child
Vitamin and Mineral Supplements for Breastfeeding Mum
Concern about Macro/Micronutrient Intake
Nutrients of Concern
Other
Please describe the food textures your child tolerates/ does not tolerate i.e. puree, lumpier textures etc
Assessment of Feeding Environment
Please upload videos of your child feeding here
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Feeding/Eating Observation
Type of Mealtime Observation
Feeding Equipment
Other
Description of Food Offered
Description of Mealtime Observation
Description of Oral Motor Skills
Summary of Advice Provided
In regard to follow-up, the parents have 3 emails (up to 250 words per email, expires after 1 year) included in this consultation. We suggest that they use these emails before making a follow up appointment with us.
Please do not hesitate to contact us for any further information you may require.
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Note for NHS GP

Correspondence after the feeding consultation
Type a question
Other
Date
MonthDayYear
Date
Type a question
Should be Empty: