Infant Feeding Case History Form

This form provides the Speech Pathologist with background information about your child. The more detail you provide, the clearer the picture of your child’s development and progress to date. This form is very detailed and may take you some time to complete so please note that you can save and continue later (please select 'save and complete later' at base of form, if required.  Please feel free to consult the Speech Pathologist if you are unsure about any aspect of this form.

First Name
Last Name
First Name
Last Name

Parent Concerns

Health Services

Birth History

Medical History

Development

Feeding History

Current eating and drinking

(select all that apply)

Sensory Preferences

(select more than one, if applicable)

Daily routine

Please include : - time of each meal or snack - types of food offered - approximate amounts usually eaten - sleep time, including any naps and when they sleep overnight

Thank you for taking the time to complete this questionnaire. Your answers will help inform the feeding assessment.