Pediatric Feeding Assessment
Patient Information
Child's Name
Date of Birth
Caregiver Name(s)
Date of Assessment
Medical & Feeding History
Medical Diagnoses
Reason for Referral
Current Feeding Method
Oral
Tube
Combination
Current Diet
Allergies
Feeding Skills & Behaviors
Oral Motor Skills
Self-Feeding Skills
Typical Feeding Duration
Feeding Difficulties Observed
Feeding Position/Posture
Environmental & Social Factors
Mealtime Environment
Caregiver Strategies
Family Concerns/Goals
Assessment Summary
Findings
Recommendations