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Child Feeding and Oral Motor Assessment

This document is a feeding questionnaire for a child that asks questions about what foods the child eats, how they are fed, favorite and avoided foods and textures, potential allergies or sensitivities, and other feeding-related information. It collects details on the child's diet, feeding process, preferences, and any medical factors like reflux that could impact feeding.

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Andrea Díaz Rodríguez
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294 views4 pages

Child Feeding and Oral Motor Assessment

This document is a feeding questionnaire for a child that asks questions about what foods the child eats, how they are fed, favorite and avoided foods and textures, potential allergies or sensitivities, and other feeding-related information. It collects details on the child's diet, feeding process, preferences, and any medical factors like reflux that could impact feeding.

Uploaded by

Andrea Díaz Rodríguez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

SPEECHKIDS

Oral Motor / Feeding Questionnaire


-Revised Oct 2011-

Child’s Name:
Birth Date: ________________________ Today’s Date:
Person completing questionnaire:

What does your child usually eat for:

Breakfast:

Lunch:

Dinner:

SECTION B: (Complete this section ONLY if your child is fed by an adult):

How is the food prepared? (Check any that apply)

_______ Regular liquid _______ Mashed soft table foods

_______ Thickened liquids ----------- Table Food cut into


very small pieces
_______ Commercial strained
baby food _______ Regular table food
(limited types)
_______ Blender prepared food
_______ Regular table food
_______ Commercial junior food (any type)
` Other:
Who usually feeds your child?

Who else can feed your child?

Where is your child fed? (In a chair? On your lap? Infant seat? Wheelchair?)
Which of these types of food are easiest for your child?

Which of these types of food are hardest for your child?

How long does it take to feed your child?

What is the average amount of food and liquid your child takes during that time?

SECTION C:
What “utensils” are used when feeding your child? (check all that apply):
Held by:
_______Bottle _______Breast _____Parent ______Child
_______ Cup _______ Straw ____ Parent ______Child
_______ Spoon _______ Fingers ____ Parent ______Child
_______ Fork _______ Other

Does your child have favorite food tastes? What are they?

Does your child have favorite food textures? What are they?

Does your child prefer food at a certain temperature? (cold, warm, hot, room temperature)?

Does your child avoid any food tastes? What are they?
Does your child avoid any food textures? What are they?

Does your child avoid any food temperatures? What are they?

Does your child have any food allergies that you are aware of?

Do any other family members have allergies? (food, chemical, pollens, mold?)

Does your child have reflux? YES NO

Does your child demonstrate open-mouthed breathing? YES NO


When?:

Does your child have frequent upper respiratory infections YES NO

Have you explored sensitivities to gluten? YES NO

Have you explored sensitivities to casein? YES NO

Please elaborate any responses that had positive indications:


Adapted from:
Copyright – Suzanne Evans Morris, Ph.D., C.C.C. and Marsha Dunn Klein, [Link], O.T.R.,
Pre-Feeding skills: A Comprehensive Resource for Feeding Development.
Food Repertoire (List Every Food You Can):

Always Accepts Sometimes Accepts Never Accepts

Feeding Questionnaire

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