Check off food your child currently eats. If your child previously accepted a food item but no longer eats the food, please circle the item.

Size: px

Start display at page:

Download "Check off food your child currently eats. If your child previously accepted a food item but no longer eats the food, please circle the item."

Jonathan Phillips
5 years ago
Views:

1 Check ff fd yur child currently eats. If yur child previusly accepted a fd item but n lnger eats the fd, please circle the item. Texture Preference: Crunchy Crisp Smth Lumpy Unifrm lumpy (i.e., cttage cheese) Hard Chewy Mixed cnsistencies Taste Preference: Salt Sweet Spicy Tart Flavred Bland Temperature Preference: Appetite: Ht Warm Cld Cl Best time f the day t eat Overall descriptin f appetite: Pr Fair Gd Varies frm day-t-day

2 Breads: Crackers Chips Pretzels Snack mix Bugles Cheese puffs Tstits/tac chips Tac shells (hard) Flur trtillas Rlls Pizza crusts Hamburger/ht dg buns Bread: white, wheat, rye, ptat, rice, gluten-free, pumpernickel, bagels, French bread Plain bread sticks Garlic bread sticks Texas tast/garlic bread Ht rlls, baked bread, crescent rlls, crissants Biscuits Dughnuts, sweet rlls, cinnamn rlls, caramel rlls Banana bread, pumpkin bread, apple bread, muffins Crn bread Cupcakes Cake, pies, pastries, Cheesecake Ckies Other

3 Meats: Baked chicken Fried chicken Chicken strips Turkey Pultry Fish (fried) Fish (baked r briled) Tuna Salmn Beef (steak, rast, deli-style) Rast Ribs Deer Hamburger Steak Ham Veal Prk Sausage Bacn Chicken r ham salad Tuna salad Meatballs Ht dgs Crn dgs Blgna Lunch meat Baby fd meat sticks Baby fd meats (what types?)

4 Nuts: Peanut butter. Peanuts Walnuts Cashews Pecans Specific brands? Ptat Prducts: French fries Tater tts Hash brwns Fried ptates Baked ptates Ptat chips Ptat wedges Shestring ptat strips Mashed ptates Mashed ptates (with butter) Mashed ptates (with gravy) Scallped/au gratin ptates Baked sweet ptates Candied sweet ptates Sweet ptat chips Sweet ptat fries Vegetable chips Other

5 Cndiments: Ketchup Maynnaise Miracle whip Mustard Dijn r spicy mustard Hney mustard BBQ sauce A1 steak sauce Chili sauce Wrcestershire sauce Ranch dressing Other salad dressings Butter r margarine Chip dip Gravy Other Breakfast Fds: Oatmeal Cream f wheat Pp tarts Dry cereal Pancakes With fruit With syrup Waffles (hmemade) Waffles (frzen) French tast Eggs Omelet Fried Biled Pached With cheese, vegetables, salsa, chpped meats, etc. Tast With cinnamn r butter With jelly With apple butter With peanut butter With hney (after age 2) Breakfast shakes Ygurt G-gurt (what types? ) Fresh fruit Grits

6 Vegetables: Green beans Brccli Cauliflwer Crn Squash Cucumber Zucchini Spinach Carrts Lettuce Cleslaw Cabbage Sweet ptates Tmates Asparagus Brussels spruts Green pepper Onin Peas Salsa Vegetable baby fd (what types) Other: Liquids: Juice (circle all that apply): range, cherry, berry, grape, fruit punch, strawberry, strawberry kiwi, cranberry fruit ccktail, white grape, pear, r ther: Lemnade Milk (circle all that apply): whle, 2%, skim Flavred milk (what types? ) Sda (circle all that apply): cla, lemn-lime, range, grape, rt beer, cream sda. Specific brands: Tea (circle all that apply): sweetened, unsweetened Milk shakes Water Other:

7 Fruit: Apple Banana Blueberry Cantalupe Cherry Grapes Kiwi Lemn Lime Orange Pear Peaches Pumpkin Watermeln Raisin Raspberry Rhubarb Strawberry Tangerine Tmat Dried fruit Other:

8 Pasta/Italian-style Dishes: Spaghetti Lasagna spagettio s/ravilio s casserles (i.e., hamburger helper) pizza pizza tppings: ther: rice dishes ndle dishes cuscus

9 Sups: Cheese Cheese and brccli Cheese and vegetables Chili Stew Vegetable Vegetable beef French nin Egg drp Beef ndle Chicken ndle Chicken and rice Other: Cheese/Dairy: Cheddar American Parmesan Swiss Mnterey Jack Mzzarella Clby Cttage cheese Sur cream Ygurt (what types? ) Cl whip Whipped cream Ice cream/sherbet (what types? )

10 Please list yur child s favrite fds/liquids: Please list yur child s least-favrite fds/liquids: What gal fds wuld yu like t see yur child eat with the rest f the family?

11 Are there times when yur child eats well? Cmments: *Fraker, C., Fishbein, M., Cx, S., & Walbert, L. (2007).Fd chaining. Cambridge: Da Cap Press. Adapted fr use at Building Blcks, Inc. by Kasey Silverman, B.F.A., SLPA

Food Chaining Intake Form

Food Chaining Intake Form Please indicate your child s preferences Texture Preferences: Crunchy Crisp Smooth Lumpy Uniform Lumpy ( ie Cottage cheese) Hard Chewy Mixed Consistencies Taste Preferences: Salty Sweet Spicy Tart Flavored