Food Chaining Intake Form

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Marylou Magdalene Thompson
5 years ago
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1 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 Bland Temperature Preferences: Hot Warm Cold Cool Food Chaining Intake Form Appetite: Best time of day to eat: Environmental Factors that change eating habits: (quiet room, lights on/off etc) Supplemental Nutrition Necessary? (Pediasure, Bright Beginnings, Just For Kids, Nutren, Peptamen Jr., Boost, Resource, NeoKate, Ellecare etc) 8502 N. Nevada St, Ste 2, Spokane, WA Phone (509) Fax (509)

2 Overall description of appetite: Poor Fair Good Varies from day to day Age selective eating began: Current approximate # of accepted foods: Current approximate # of accepted liquids: Please mark the foods your child eats in the appropriate columns Will Eat consistently Have Tried/ Tasted (inconsistent) Have Offered FOOD (refused) BREADS Crackers Chips Pretzels Snack Mix Bugles Cheese Puffs Doritos Taco Shells (hard) Flour tortillas Rolls Pizza Crust Hamburger or hot dog buns Bread (white, wheat, rye, potato, rice, gluten free, pumpernickel, bagel, French bread) Bread sticks Garlic bread Hot rolls, baked bread, crescent rolls, croissants Biscuits Doughnuts, sweet rolls, cinnamon rolls, caramel rolls Banana bread, pumpkin bread, apple bread, muffins Corn bread Cupcakes Cake, pies, pastries

3 Cookies MEATS Baked chicken Fried Chicken Chicken strips Chicken nuggets Turkey Fried Fish Baked or Broiled fish Tuna Salmon Beef Roast Ribs Deer Hamburger Steak Ham Veal Pork Sausage Bacon Chicken or ham salad Meatballs Hot dogs Corn dogs Bologna Lunch meat Little smokies Baby food meat sticks Baby food meats: NUTS Peanut butter Peanuts Walnuts Cashews Almonds Pecans POTATO PRODUCTS French fries Tater tots

4 Hash browns Fried potatoes Baked potatoes Potato wedges Mashed potatoes (plain, butter, gravy) Scalloped potatoes Bakes sweet potatoes Sweet potato chips or fries Vegetable chips CONDIMENTS Ketchup Mayo Miracle Whip Mustard Dijon or spicy mustard Honey mustard BBQ sauce A1 steak sauce Chili sauce Worcestershire sauce Ranch dressing Other dressing Butter/margarine Gravy Chip dip BREAKFAST FOODS Oatmeal Cream of Wheat Pop Tarts Dry Cereal Pancakes Waffles French toast Eggs (scrambled, omelet, fried, boiled, poached, with cheese, vegetables, salsa chopped meats, etc) Toast (cinnamon sugar, jelly, peanut butter, honey, plain) Breakfast shakes Yogurt / Go-Gurt Grits

5 VEGETABLES Green beans Brocolli Cauliflower Corn Squash Cucumber Zucchini Spinach Carrots Lettuce Coleslaw Cabbage Sweet Potatoes Tomatoes Asparagus Green Pepper Onion Peas Salsa Vegetable baby food LIQUIDS Juice (what kind(s): ) Lemonade Milk Flavored milk Soda Tea Milk Shakes Floats Drinkable Yogurt Water Caloric Supplement (Pediasure, Bright Beginnings, Just For Kids, Nutren, Peptamen Jr., Boost, Resource, NeoKate, Ellecare) FRUITS Apple Banana Blueberry Canteloupe

6 Cherry Grapes Kiwi Lemon Lime Orange Pear Pumpkin Watermelon Raisin Raspberry Rhubarb Strawberry Tangerine Tomato Dried fruit PASTA/ITALIAN Spaghetti Lasagna Spaghetti Os Ravioli Pizza Rice Dishes Noodle Dishes Couscous SOUPS Cheese Cheese and Brocolli Vegetable Chili Stew Vegetable Beef French Onion Egg Drop Beef Noodle Chicken Noodle Chicken and Rice Potato Clam Chowder Tomato Hot and Sour

7 Tortilla Lentil/Split Pea CHEESE/DAIRY Cheddar, American, Parmesan, Swiss, Monterey Jack, Mozzarella, Colby, Brie, Feta, Blue, Gorgonzola Cottage Cheese Sour Cream Yogurt (what type: ) Cool Whip Whipped Cream Ice Cream (what type: ) Sherbet (what type: ) Fast Food: Please List your child s favorite foods and drinks: Please list your child s least favorite foods and drinks: What goal foods would you like to see your child eat with the rest of the family? Please list your child s medications: Please list any chronic conditions that affect feeding (reflux, vomiting, constipation etc):

8 Comments:

Food Inventory Preferences

Food Inventory Preferences Patient Name: Evaluation Date: DOB: Texture Preferences: Crunchy Crisp Smooth Lumpy Uniform Lumpy (cottage cheese texture) Hard Chewy Mixed Consistencies Taste Preferences: Salty Sweet Spicy Tart Flavored