Feeding Evaluation Δ Child's Name(Required)Age(Required)DOB(Required) Month Day Year Date Completed(Required) Month Day Year Completed by:(Required)Name and relation to patientRevised?(Required) Yes No Previous feeding therapy with ST OT Was your childCheck all that apply Breast fed Bottle fed Ate baby food Eats table foods Happy with the current amount of intake?(Required) Yes No Have you had a swallow study done?(Required) Yes No Describe any difficulties with transitions or if they struggled with any stages of foodsAre they currentlyCheck all that apply Drinking from a bottle Drinking from a sippy cup Drinking from a straw Drinking from an open cup Using spoon Using fork Meal time behaviorsCheck all that apply Coughing Choking Spit up Vomit Turns head Pushes food away Runs away Crys Arches Diagnosed with Reflux Constipation MedicationsAllergiesDiagnosed withCheck all that apply Tongue tie Lip tie Cheek tie