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Feeding and OFM Case History 2018

Home / Initiating Service / Feeding and OFM Case History 2018

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PO Box 34
Victoria, MN 55386

FAX: 952-443-9804
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Your case history and any other requested information must be received no later than one week before your scheduled appointment.

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Child's Name
Feeding and Swallowing History
What is your primary concern? (please explain in detail)
Were you referred by another professional?
- Gastroenterologist
- Pediatrician
- Psychologist
- Orthodontist/Dentist
- Other
When did you first notice the problem? (please explain in detail)
Has your child ever had feeding therapy?
- No
- Yes (please provide copies of any therapy reports)
Has your child ever had a video swallow study?
- No
- Yes (please provide copy of the results)
Was or is your child fed through a feeding tube?
- No
- Yes (for how long and what were they fed)
What age were pureed foods introduced?
Any difficulties eating table foods?
- Gas
- Decreased intake
- Bloating
- Crying
- Gagging
- Appears to be difficult
- Vomiting
- Coughing after drinking
What age were table foods introduced?
Any difficulties eating table foods?
- Gas
- Decreased intake
- Bloating
- Crying
- Gagging
- Appears to be difficult
- Vomiting
- Coughing after drinking
Any difficulties drinking liquids?
- Gas
- Decreased intake
- Bloating
- Crying
- Gagging
- Appears to be difficult
- Vomiting
- Coughing after drinking
How long does it take your child to complete a meal?
- Less than 10 minutes
- 10-20 minutes
- 20-30 minutes
- Over 30 minutes
Describe the environment during a mealtime? (i.e. noisy, quiet, distracting)

Speech History
Does your child have any speech sound concerns?
- Yes
- No
Describe speech sound concerns
How does your child currently communicate?
- gestures/body language
- sounds/grunting
- single words
- short phrases
- sentences
- other
Describe other communication
Was your child a late talker?
- Yes
- No
Did your child have an early language delay?
- Yes
- No

Professional Contact Information
Dentist's Name
Dentist's Phone
Feeding/Speech Therapist's Name
Feeding/Speech Therapist's Phone
Physician's Name
Physician's Phone
Other
Phone
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