You may use the following form to print and bring to your child's ...

You may use the following form to print and bring to your child’s Functional FeedingEvaluation. This information may be used to gain more knowledge of your child’sfood repertoire in the home environment.What texture of foods will your child eat?_____smooth_____chewy_____soft crunchy (easily dissolvable)_____hard crunchy_____lumpy_____mixed texturesPreferred texture______________________What taste of foods will your child eat?_____sweet_____salty_____bland_____spicy_____sourPreferred taste________________________Food Inventory ChecklistWhat temperature of foods will your child eat?_____cold_____hot_____warm_____room temperaturePreferred temperature___________________What is your child’s favorite food? _______________________________________What is your child’s least favorite food? ___________________________________Does your child eat best at a certain time of day?___________________________How would you best describe your child’s oral intake?_____poor, refuses most foods_____picky, only eats certain foods_____inconsistent_____will put most any foods in mouth to eat but little volume_____good appetiteBased on the following food category groups, indicate your child’s response to any of thefoods listed below (1 – eats well and swallows food, 2- lets food in mouth but does notreally chew or swallow it, 3 – licks or tastes food only, 4 – refuses food)

_____kiwi _____lemon _____lime_____orange _____pear _____pumpkin_____raisins _____raspberry _____strawberry_____watermelon _____dried fruitsSOUPS_____cheese _____chili _____stew_____vegetable _____chicken noodle _____otherBREAKFAST FOODS_____oatmeal _____cream of wheat _____pop tarts_____dry cereal _____pancakes _____waffles_____toast _____biscuit _____eggs_____yogurt _____grits _____fruit_____fruit barFAST FOODS____________________________________________________________________________________________________________________________________CONDIMENTS/SAUCES_____ketchup _____mayonnaise _____mustard_____BBQ sauce _____salsa _____ranch dressing_____butter _____gravy _____syrup_____dip_____salad dressingLIQUIDS_____juice _____lemonade _____milk_____water _____tea _____shake_____formula_____sodaOther:__________________________________________________________________________________________________________________________________________________________________________________________________________