Historial de alimentación detallado Complete el historial de alimentación detallado Detailed Feeding History Child's Name* First * Last Date of Birth* MM slash DD slash YYYY Caregiver's Email* Please explain what your child's current feeding challenges are.*Was your child breast fed?* Yes No From when to when Was your child bottle fed?* Yes No From when to when Please describe your child's initial skill on the breast and/or bottle.*During these early feedings, did your child frequently:* Arch Cry Spit up Gag Cough Vomit Detach from nipple None of the above If any of the above behaviors occurred, please describe when they would occur, why they occurred, and how long they lasted. Please type N/A if these behaviors did not apply to your child.*Describe how the weaning process off the breast and/or bottle went and why the child was weaned.*At what age was your child introduced to baby cereal?* At what age was your child introduced to baby food?* At what age was your child introduced to finger foods?* At what age was your child introduced to table foods?* When did your child transition fully to table food?* If your child eats by mouth, please answer the following questions:List the foods that your child will currently eat and drink. Please make note of their favorites:List the foods your child refuses:List any foods your child is allergic to:Describe your child's mealtime:Who typically feeds your child?* Who typically eats with your child?* What type of chair is used?* How long are meals typically?* Does your child use utensils or any type of special cups/bowls? Please describe.* Are there any other activities going on at meals? Please describe..* What times does your child typically eat and what type (bottle, breast, solids)?If your child is tube fed, please answer the following questions:What type of formula is used and exactly how do you mix it?Describe where your child is tube fed and what activities are occurring at the same time:Describe your child's reactions to the tube feedings (connecting, during, disconnecting):Please describe how these transitions were handled by your child, especially if any difficulties occurred:Please detail your child's feeding schedule below (time of feeding, NG/G/Continuous, Amount, Gravity/Pump, Over what time period/what rate)::Please answer for all children:Has your child ever been on any type of special diet other than what you just described?* Yes No If yes, please describe the type of diet, at what ages, why, and what your child's response to the diet was. If no, please type N/A.*How do you know your child is hungry?*How do you know your child is full?*Has your child lost or gained any weight in the last 6 months? How much?*Would you describe your child's weight as (choose one): Ideal, Underweight, or Overweight?*Does your child have/had any of the following problems (choose which ones and describe): Dental, frequent constipation, frequent diarrhea, vomiting, choking, gagging, or coughing.*Does your child take a vitamin supplement? Which one?* Describe how YOU feel after your child's feeding.*Describe how YOUR CHILD feels after a feeding.*What other evaluations have been completed regarding your child's feeding difficulties and what were the results/what were you told?*What treatments have been tried from this problem, and what were the results?*How can we be most helpful to you and your child?*
