Transcription of Feeding Evaluation Questionnaire - CHOC
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Feeding Evaluation Questionnaire - CHOC
MULTIDISCIPLINARY PEDIATRIC Feeding PROGRAM SCREENING Questionnaire Questionnaire PAGE ___ OF ___ Name: MR #: DOB: Multidisciplinary Feeding Program 1201 W. La Veta Orange, CA 92868 (714) 509-4884 BACKGROUND INFORMATION 1. Child s Name: 2. Date of Birth: / / 3. Gender: Male Female 4. Parent/Guardian(s) Name(s): 5. Marital Status: Married Single Divorced Separated Widowed Other:_____ 6. List of People Currently Living in the Household: Name Relationship to Child Age 7.
Spank Limit foods Offer small meals Offer reward Send to time-out Distract with play/toys Change meal schedule Praise Use TV/Video Ignore Other: 44. What are your goals for therapy? (check all that apply) Increase amount of food Increase variety of foods Decrease/eliminate tube feeds Increase the textures of food
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