Sweet Pea Therapy – Ottawa Occupational Therapist Specializing in Feeding.

Lactation Consultant – Breastfeeding – Reflux

Carrie Owen - Occupational Therapist Reg. (ON)
info@sweetpeatherapy.com
613-277-3155

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Contact Sweet Pea Occupational Therapy

Happily helping families throughout the greater Ottawa area

Contact information

Carrie Owen, O.T. Reg. (ON)
Lactation Consultant
Occupational Therapist

I help families in the greater Ottawa region. Call or email to schedule an appointment or send me a message via the form.

Telephone:

613-277-3155

Email:

info@sweetpeatherapy.com

Send us a message

Contact form

"*" indicates required fields

Name*
First Last
Email*

Phone
How can we help?

Feeding Intake Form

Please answer the following questions regarding your child’s eating habits. This will help us understand your child’s strengths and areas of challenges with feeding. Add any additional comments in the column on the right if needed

Name*
First Last
Email*

Child's Date of birth*
Phone
Child's Name
First Last
Current medication if applicable
Current known allergies if applicable
Date of Feeding Study and Results
Feeding information
How many scheduled meals and snacks does your child eat per day?
none
one
two
three
more than three
How many bottles of milk does your child drink?
six or more
five
four
three
two or less
How many bottles of formula?
How often does your child breastfeed?.
How many cups or sippy cups of milk does your child drink?
six or more
five
four
three
two or less
Does your child use any of these products in their day? (check all that apply)
If you answered yes to the previous question, how many times a day?
more than three times
3 times
twice
once
How many cups (8 oz or 250 ml) of water does your child drink per day?
more than 7
6
5
three/four
two/three
How many cups (8 oz or 250 ml) of juice does your child drink per day?
more than 7
6
5
three/four
two/three
How often does your child wake up to feed/eat /drink during the night?
more than 7
four/five
three
one/two
none
How many meals a day does it take 10 minutes to 30 minutes for your child to eat?
3 meals + snacks
three
two
one
none
How many meals/snacks a day does your child sit to eat?
four or more
three
two
one
none
How many meals and snacks a day does your child eat in the kitchen/dining area?
four or more
three
two
one
none
How many meals/snacks does your child eat with the family?
four or more
three
two
one
none
How frequently does your child require distractions per day such as iPad, iPhone, TV, books, toys?
more than three times
three
twice
once
never
How frequently does your child eat the following types of foods: a. pureed (ex: applesauce, yogurt)
always
often
sometimes
rarely
never
How frequently does your child eat the following types of foods: b. soft/minced (ex: avocado, pasta)
always
often
sometimes
rarely
never
How frequently does your child eat the following types of foods: c. crunchy (ex: crackers, cookies)
always
often
sometimes
rarely
never
What food groups does your child eat from? (circle all that apply)
Do you feel your child eats enough?
never
once/day
twice/day
3x/day
4x/day or more
Does your child gag or vomit when presented with food in his/her mouth?
Gags/vomits/chokes/pockets or holds food in his cheeks/chews slowly/spits
daily
once/week
>twice/week
less than once/week
< monthly
How frequently can your child self-feed using their fingers or utensils/day?
Bottle/breast only = never
never
once
twice
three times
more than three times
Does your child have regular bowel movements?
Constipation (brittle, < 2 days)/diarrhea
no
once /2 days
daily and hard
some hard
normal and daily
Are you or other family members concerned about your child’s eating?
very much
frequently
sometimes
rarely
not at all
As a parent, do you feel confident with your mealtime approach?
very much
frequently
sometimes
rarely
not at all
Are mealtimes pleasant and are family members relaxed and calm?
Leaves table/tantrums/throws
always
often
sometimes
rarely
never
How does your child behave during mealtimes?
Acts up/makes a fuss at all meals and snacks
Behaves well at 1 meal and/or during snacks
Behaves well at 2 meals
Behaves well at 3 meals
Behaves well at all meals and snacks
Family Information
If the child’s parents are separated or divorced, who has custody?
One Parent
Joint Custody
If one parent, give name of parent
Would any of the following make it difficult for you to bring your child to treatment?
If there are additional reasons for the above question, please specify
Does your child attend daycare?

yes

no
Previous Assessment
Please check if your child has been seen by or referred to any of the following:
If yes to any of the above, please specify details of dates and location for visits/assessments.
What is your main concern regarding your child’s eating at this time?
Is there any additional information that you would like to share?

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