TheraKids Plus, Inc. Feeding / Swallowing Questionnaire Feeding Questionnaire - English Patient Name(Required) First Last Contact Telephone Number Date of Birth(Required) MM slash DD slash YYYY FEEDING / SWALLOWINGHas your child been diagnosed with a swallowing disorder and/or aspiration? YES NO Describe: Does your child have food allergies? YES NO Describe: Please check all that your child is displaying:Checkbox Sensitive to food tastes Sensitive to food textures Choking on solids Choking on liquids Spitting up after bottle feeding Hold food or liquid in mouth / pocketing food Overstuffs mouth Poor lip control / drools Grinds teeth Checkbox Sucks thumb / fingers Uses a pacifier past the age of one year Refuses food based on appearance Only eats specific types of foods (ex: McDonald’s Fries) Arching back while bottle feeding Vomiting after eating Puts inedible objects in mouth Has trouble blowing whistles / bubbles Noisy breathing / snoring Please check all that apply to your child: SkillFinger Feeds Independent (90- 100% of time) Emerging (50% of time) Not Yet Achieved Finger Feeds Independent (90- 100% of time) Emerging (50% of time) Not Yet Achieved Uses a fork Independent (90- 100% of time) Emerging (50% of time) Not Yet Achieved Uses a knife Independent (90- 100% of time) Emerging (50% of time) Not Yet Achieved Drinks from a sippy cup Independent (90- 100% of time) Emerging (50% of time) Not Yet Achieved Drinks from an open cup with no spilling Independent (90- 100% of time) Emerging (50% of time) Not Yet Achieved Uses a straw Independent (90- 100% of time) Emerging (50% of time) Not Yet Achieved Is your child on a special diet? Yes No Describe: Do you thicken your child’s liquids? Yes No Describe: Does your child have a Gastrostomy Tube? Yes No Mic-Key Button ? Yes No Feeding schedule: Bolus Pump Type of formula: Untitled
