P e d i a t r i c

  F e e d i n g   H i s t o r y   a n d   C l i n i c a l   A s s e s s m e n t   T e m p l a t e      1  
                           
( L i q u i d ,   P u r e e d ,   S o l i d ) |    
 
A. Preliminary  Information  
Reason  for  referral:  _________________________________________________________________  
Chronological  age  (Adjusted  age):  ________________________________________________  
Primary  caregiver:  __________________________________________________________________  
Informant  for  evaluation:  ___________________________________________________________  
Primary  language:  __________________      Interpreter    
Family  concerns  ____________________________________________________________________  
 Barriers  to  learning:  ___________________________________________________________  
 
B. Background  Information  
B1.  Summary    
Medical  team  (physicians,  dentists,  etc):  
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________  
 
Ancillary  care  team  (nursing,  therapists,  etc):  
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________  
 
Previous  Hospitalizations:  
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________  
 
Previous  Surgeries:  
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________  
 
Medications:  
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________  
 
Allergies/Intolerances:  
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________  
 
Cultural  preferences  relevant  to  feeding:  
_____________________________________________________________________________________________
_____________________________________________________________________________________________  
 
Templates  are  consensus-­based  and  provided  as  a  resource  for  members  of  the  American  Speech-­  
Language-­Hearing  Association  (ASHA).  Information  included  in  these  templates  does  not  represent  
official  ASHA  policy.  
 
 P e d i a t r i c   F e e d i n g   H i s t o r y   a n d   C l i n i c a l   A s s e s s m e n t   T e m p l a t e      2  
                           
( L i q u i d ,   P u r e e d ,   S o l i d ) |    
 
B2.  Birth  History  
 Complications  during  pregnancy:  _____________________________________    
Delivery:  
 Vaginal    Cesarean-­‐section:  (reason)  _________________________
 Single  Birth  Multiple  Birth:  (define)  ________________________    
 Complications  during  delivery:  _______________________________________  
 Term      Preterm:  _______________(weeks/days)  
     NICU:  (describe)  _______________________________________________  
Birth  weight:  ___________    
 APGAR  Scores:  _____  @  1m,  _____  @  5  m,  _____  @  10  m  
 
B3.   Congenital  malformations,  deformations,  and  chromosomal  abnormalities  
Details  including  treatment:  ________________________________________________________  
_________________________________________________________________________________________  
 
B4.   Conditions/Disorders/Diseases  of  the  nervous  system  
Details  including  treatment:  ________________________________________________________  
_________________________________________________________________________________________  
 
B5.   Conditions/Disorders/Diseases  of  the  circulatory  system  
Details  including  treatment:  ________________________________________________________  
_________________________________________________________________________________________  
 
B6.   Conditions/Disorders/Diseases  of  the  respiratory  system  
Details  including  treatment:  ________________________________________________________  
_________________________________________________________________________________________  
 
B7.     Conditions/Disorders/Diseases  of  the  digestive  system  
Details  including  treatment:  ________________________________________________________  
_________________________________________________________________________________________  
 
B8.   Conditions/Disorders/Diseases  of  the  musculoskeletal  system  and  
connective  tissue  
Details  including  treatment:  ________________________________________________________  
_________________________________________________________________________________________  
 
B9.   Neoplasms    
Details  including  location  of  neoplasm  &  treatment:  _____________________________  
_________________________________________________________________________________________  
 
B10.   Mental,  behavioral,  and  neurodevelopmental  disorders    
Details  including  treatment:  ________________________________________________________  
_________________________________________________________________________________________  
 
 
Templates  are  consensus-­based  and  provided  as  a  resource  for  members  of  the  American  Speech-­  
Language-­Hearing  Association  (ASHA).  Information  included  in  these  templates  does  not  represent  
official  ASHA  policy.  
 
 P e d i a t r i c   F e e d i n g   H i s t o r y   a n d   C l i n i c a l   A s s e s s m e n t   T e m p l a t e      3  
                           
( L i q u i d ,   P u r e e d ,   S o l i d ) |    
 
B11.   Injury,  poisoning  and  other  consequences  of  external  causes  
Details  including  treatment:  ________________________________________________________  
_________________________________________________________________________________________  
 
B12.   Hearing  impairment:  _____________________________________________________________    
     
B13.   Visual  impairment:  _______________________________________________________________  
 
B14.   Diagnostic  procedures  completed  (dates  &  results)  
  MBS/VFSS:  _____________________________________________________________________  
  FEES:  ____________________________________________________________________________  
  pH/Impedance  probe:  _________________________________________________________  
  Upper  GI:  _______________________________________________________________________  
  Gastric  emptying/Milk  Scan:  __________________________________________________  
  Other:  ___________________________________________________________________________  
 
B15.  Swallowing/Feeding  &  Nutrition  History  
 
 Breastfeeding:      
 

 Bottle  feeding:      
 

 Spoon  from  caregiver:      

 Fingers  (self):      
 

 No  spill  cup:              
 

 Straw:  
 

 Utensils  (self):      
 

 Open  cup:  
 

 Alternate  feeding  methods  (tube  feeding,  parenteral  nutrition,  etc…)

Templates  are  consensus-­based  and  provided  as  a  resource  for  members  of  the  American  Speech-­  
Language-­Hearing  Association  (ASHA).  Information  included  in  these  templates  does  not  represent  
official  ASHA  policy.  
 
 P e d i a t r i c   F e e d i n g   H i s t o r y   a n d   C l i n i c a l   A s s e s s m e n t   T e m p l a t e      4  
                           
( L i q u i d ,   P u r e e d ,   S o l i d ) |    
 
Historically,  child  consumes  adequate  amount  and  variety  of:  
    Comment  if  No  
Liquids    Yes    No    

Fruits    Yes    No    

Vegetables    Yes    No    

Grains    Yes    No    

Dairy    Yes    No    

Meats    Yes    No    

 
History  of:  
 Dehydration  
 Poor  Weight  Gain  
 Coughing/choking  during  or  after  eating/drinking  
 Gagging/vomiting  during  or  after  eating/drinking  
 Wet  vocal  quality  during  or  after  eating/drinking  
 Problematic  behaviors  during  or  after  eating/drinking  
Details:  _______________________________________________________________________________________  
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Templates  are  consensus-­based  and  provided  as  a  resource  for  members  of  the  American  Speech-­  
Language-­Hearing  Association  (ASHA).  Information  included  in  these  templates  does  not  represent  
official  ASHA  policy.  
 
 P e d i a t r i c   F e e d i n g   H i s t o r y   a n d   C l i n i c a l   A s s e s s m e n t   T e m p l a t e      5  
                           
( L i q u i d ,   P u r e e d ,   S o l i d ) |    
 
 
C.  Evaluation  Information  
Number  of  meals/snacks  offered  each  day:  _________________________________  
Average  length  of  meal/snack  times:  _______________________________________  
 Routine  for  meal/snack  times:  ________________________________________________  
Typical  position  for  feeding:  ________________________________________________________  
Fed  by:    Self    Others:  _______________________________________________  
 Sensory  preferences:  ________________________________________________________  
 Modifications  to  food  or  fluid:  ______________________________________________  
 Use  of  additives  or  supplements:  __________________________________________  
 
Before  assessment:  
State:  _______________________________________   Respiratory  Rate:  ___________________  
Oxygen  saturation:  _______________________   Pain  Assessment:  ___________________  
 
Assessment  
Oral  Motor/Peripheral  
All  structures  observed    Yes         No  
List  structures  not  observed:  _______________________________________________  
All  structures  within  expected  limits  for  age,  sex,  race:    Yes         No  
Details  if  no:  _________________________________________________________________  
Movement  patterns,  tone,  and  reflexes  are  appropriate  for  age  
 Yes         No
Details  if  no:  _________________________________________________________________  
 
Non-­‐Nutritive  Suckling/Sucking:   Not  applicable  Adequate    
 Impaired  
Describe:  _____________________________________________________________________________  
 
Oral  sensory  response  
 Functional         Signs  of  hypersensitivity    Signs  of  hyposensitivity  
Describe:  _____________________________________________________________________________  
 
Adequate  secretion  management:    Yes         No  
Describe  if  no:  _______________________________________________________________________  
 
Phonation:    Functional         Impaired  Not  applicable  (i.e.  trach)  
Describe  if  impaired:  ________________________________________________________________  
 
Signs  of  stress  during  assessment:    Yes         No  
Describe  if  yes:  ________________________________________________________________  
 
 
 
 
Templates  are  consensus-­based  and  provided  as  a  resource  for  members  of  the  American  Speech-­  
Language-­Hearing  Association  (ASHA).  Information  included  in  these  templates  does  not  represent  
official  ASHA  policy.  
 
 P e d i a t r i c   F e e d i n g   H i s t o r y   a n d   C l i n i c a l   A s s e s s m e n t   T e m p l a t e      6  
                           
( L i q u i d ,   P u r e e d ,   S o l i d ) |    
 
  Oral  Feeding  
Position(s)  during  feeding:  _________________________________________________________  
 
 Pureed  foods  trialed:  ___________________________________________________________  
  Fed  by:    Self         Caregiver    Clinician  
  Spoon  feeding  skills  were  appropriate  for  age:    Yes         No  
  Details  if  no:  _________________________________________________________________  
  Compensatory  strategies  trialed:  __________________________________________  
  Results  of  compensatory  strategies:  _______________________________________  
 
 Solid  foods  trialed:  ___________________________________________________________  
  Fed  by:    Self         Caregiver    Clinician  
  Biting/chewing  skills  were  appropriate  for  age:    Yes         No  
  Details  if  no:  _________________________________________________________________  
  Compensatory  strategies  trialed:  __________________________________________  
  Results  of  compensatory  strategies:  _______________________________________  
 
 Liquids  trialed:  _________________________________________________________________  
  Fed  by:    Self         Caregiver    Clinician  
  Drank  from:   Lidded  cup         Straw    Open  cup  
 Bottle         Other:  _____________________________________  
  Drinking  skills  were  appropriate  for  age:    Yes         No  
  Details  if  no:  _________________________________________________________________  
  Compensatory  strategies  trialed:  __________________________________________  
  Results  of  compensatory  strategies:  _______________________________________  
 
 Concern  for  pharyngeal  phase  dysfunction:  _________________________________  
 Concern  for  esophageal  phase  dysfunction:  _________________________________  
 Disruptive  feeding  behavior:  ______________________________________________  
Oral  sensory  response:    
  Functional    Signs  of  hypersensitivity  Signs  of  hyposensitivity    
Comments:  ___________________________________________________________________  
 
After  assessment:  
State:  _______________________________________   Respiratory  Rate:  ___________________  
Oxygen  saturation:  _______________________   Pain  Assessment:  ___________________    
Other  observations:  _________________________________________________________________  
 
D.  Clinical  Summary  
(Patient  name)  is  a  (age)  (gender)  that  presents  with  
(functional/dysfunctional)  oral  feeding  skills  characterized  by  _______________.  
Prognosis  for  safe  oral  intake:   Good    Fair    Poor  
Prognosis  for  adequate  oral  intake:   Good    Fair    Poor  
Strengths:  ____________________________________________________________________________  
Concerns:  ____________________________________________________________________________  
Templates  are  consensus-­based  and  provided  as  a  resource  for  members  of  the  American  Speech-­  
Language-­Hearing  Association  (ASHA).  Information  included  in  these  templates  does  not  represent  
official  ASHA  policy.  
 
 P e d i a t r i c   F e e d i n g   H i s t o r y   a n d   C l i n i c a l   A s s e s s m e n t   T e m p l a t e      7  
                           
( L i q u i d ,   P u r e e d ,   S o l i d ) |    
 
     
Diagnosis/ICD10:  
   Dysphagia,  unspecified  R13.10    
 Dysphagia,  oral  phase  R13.11  
 Dysphagia,  oropharyngeal  phase  R13.12    
 Other:  ____________________________________________________________________________  
   
Recommendations:  
   Continue  oral  feeding,  no  modifications  
 Continue  oral  feeding  with  the  following  modifications:  ___________________  
  ________________________________________________________________________________  
   Instrumental  evaluation  of  swallow  function  
        MBS/VFSS    FEES  
        Other:  ________________________  
   Feeding  therapy  (see  plan  of  care)  
   Refer  to    
     Registered  dietitian      Gastroenterologist  
     Pulmonologist        Developmental  pediatrician  
     Other:  ___________________________________________________________    
   Additional  recommendations:  _________________________________________________  
                 ____________________________________________________________________________________  
                 ____________________________________________________________________________________  
   
Plan  of  care:  
  Speech  therapy  intervention  (is/  is  not)  recommended  for  (number  of  times/  
week)  for  (time  of  session,  such  as  30  minutes)  as  tolerated  for  at  least  
(number  of  weeks/months).    Interventions  include  but  are  not  limited  to  the  
following:  
_________________________________________________________________________________________  
Long  term  goals:  _____________________________________________________________________  
_________________________________________________________________________________________  
Short  term  goals:  ____________________________________________________________________  
_________________________________________________________________________________________  
 
 Education  provided  to  family  regarding  results,  recommendations,  and  
plan.  
 Barriers  to  learning:  ___________________________________________________________  
 Family  demonstrated  understanding  of  results,  recommendations,  and  
plan.    
 Reinforcement  needed:  ________________________________________________________  
 

Templates  are  consensus-­based  and  provided  as  a  resource  for  members  of  the  American  Speech-­  
Language-­Hearing  Association  (ASHA).  Information  included  in  these  templates  does  not  represent  
official  ASHA  policy.