Professional Documents
Culture Documents
Feeding Program Intake Form
Feeding Program Intake Form
Feeding Program Intake Form
I. Particular Needs
Cultural considerations:
Do you speak English? q Yes q No Do you need an interpreter? q Yes q No
Are there any cultural or religious practices regarding food or affecting how we care for your child?
q Yes q No
If so, describe: _____________________________________________________________________________________
Does your child receive therapy? How often? Where? For Feeding?
OCC-408 Comprehensive Pediatric Feeding and Swallowing Program Intake Form 01/09; Revised 12/3/20 Page 2 of 3
On average, how many ounces does your child drink a day? _________________ ounces
How many meals/snacks does your child usually eat in a day? ______meals _____snacks
OCC-408 Comprehensive Pediatric Feeding and Swallowing Program Intake Form 01/09; Revised 12/3/20 Page 3 of 3