Additional Feeding Information Please complete all sections of this form to help us best match your child with a therapist from our team. Parent Name(Required) First Last Email(Required) Phone(Required)Child's Name(Required) First Last My child has a diagnosis of/has been treated for:(Required) Tongue or lip ties Torticollis Reflux Allergies Enlarged Adenoids Enlarged Tonsils Surgery for adenoids or tonsils Laryngomalacia Autism Spectrum Disorder Down Syndrome Cerebral Palsy Other None If other, please listMy child is currently/previously been seen by/for:(Required) Lactation Consultant Physical Therapist Occupational Therapist ENT – Ear Nose and Throat/ Otolaryngology Gastroenterology (GI) Dietician Chiropractic Massage or craniosacral therapist Pediatric Dentist Feeding Therapy Videofluroscopic Swallow Study None Please explainSensory System (please check all that apply):(Required) Strong food preferences Strong preference for certain flavors Strong preference for certain textures Eats no fruits Eats no vegetables Eats less than 10 foods Eats less than 20 foods. My child does not/ did not self feed w/ fingers and hands. My child does not/ did not mouth/orally explore toys or fingers Appears anxious around foods Has been diagnosed with sensory processing disorder None of the above Oral-Motor & Swallowing (please check all that apply):(Required) Breathing/speech sounds louder, raspy, hoarse, wet during/after eating/ drinking/ nursing Coughs when drinking Coughs when eating Coughs on food or liquids frequently Has difficulty chewing Takes a long time to finish a meal Stuffs food in mouth Doesn’t seem to chew food/swallows whole May pocket food in cheeks or hold onto it in mouth for long periods of time. Gags on food Has choked on food Has been told child aspirates food Has been recommended for a swallow study None of the above Growth (please check all that apply):(Required) My child is overweight My child is on track on the growth chart My child is underweight/ low on the growth chart My child is extremely underweight/ has fallen off the growth chart My child struggles to eat enough to meet his/her dietary needs My child has lost weight My child has a low appetite My child has a feeding tube Breastfeeding History (please explain current concern or any previous concerns, noting any difficulty related to: weak latch, weak suck, prolonged/frequent nursing or pain when nursing.)(Required)Bottle Feeding History (please explain current concern or any previous concerns, noting any difficulty related to: weak latch, weak suck, prolonged/frequent feeding, or bottle refusal.)(Required)Solid Feeding History (please explain current concern or any previous concerns, noting any difficulty related to: transitioning to solids, range of foods, volume, family dynamics, etc. )(Required)Please explain any difficulties or concerns regarding feeding not explained above: