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    Imfed Questionnaire

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    bentoe
    The document is a form for parents to complete to provide information about their child's feeding difficulties to discuss with a doctor. It includes questions about symptoms the child experiences, descriptions of the child's eating behaviors, background information like birth weight and parent heights, and details about what foods the child does and does not eat.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Imfed Questionnaire

    Uploaded by

    bentoe
    136 views2 pages
    The document is a form for parents to complete to provide information about their child's feeding difficulties to discuss with a doctor. It includes questions about symptoms the child experiences, descriptions of the child's eating behaviors, background information like birth weight and parent heights, and details about what foods the child does and does not eat.

    Original Description:

    kuiz

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    The document is a form for parents to complete to provide information about their child's feeding difficulties to discuss with a doctor. It includes questions about symptoms the child experiences, descriptions of the child's eating behaviors, background information like birth weight and parent heights, and details about what foods the child does and does not eat.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    136 views2 pages

    Imfed Questionnaire

    Uploaded by

    bentoe
    The document is a form for parents to complete to provide information about their child's feeding difficulties to discuss with a doctor. It includes questions about symptoms the child experiences, descriptions of the child's eating behaviors, background information like birth weight and parent heights, and details about what foods the child does and does not eat.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 2

    If you are concerned that your child has a feeding problem, please complete this form

    by checking the boxes and review it with the doctor

    Child’s name ___________________________ Child’s height ______________________ (cm) for children


    Identification and management
    Child’s age ___________________________ Child’s weight ______________________ (kg) of feeding difficulties

    Date _________________________________ Child’s head circumference __________ (cm)

    1. Does your child have any of the following My child has a poor appetite, and
    symptoms? (check all the boxes ✔ that apply) (check the box or boxes that best apply):

    a. a. Choking or pain with swallowing c. My child

    b. b. Weight loss Was small at birth or premature


    c. c. Vomiting Has one or both parents who are small
    or grew slowly
    d. d. Diarrhea
    Seems healthy and active
    e. e. Blood in stool
    f. f. Food allergies
    d. My child
    g. g. Eczema or hives
    Is not interested in food
    h. h. Asthma
    Stops eating after a few bites
    i. i. Frequent infections Constantly tries to get out of the high
    j. j. Delayed development chair or to leave the table
    Enjoys playing and interacting with
    2. Check the box next to the description that familiar people
    most sounds like your child
    a. My child
    e. My child
    Gets hungry, readily begins eating but then
    pulls back and refuses to continue Is withdrawn and irritable
    Does not smile, babble, or talk much
    b. My child Shows little interest in playing
    Eats a limited number of foods
    Refuses foods because of smell, taste,
    f. My child
    texture, temperature and/or appearance
    Cries at the sight of food or feeding device
    Only accepts foods prepared in a
    (eg, bottle, spoon, or high chair)
    specific way
    Is intensely resistant to feeding
    Is reluctant to try new foods
    Started refusing food after a frightening feeding
    experience such as choking or vomiting
    Is or was tube-fed and fears eating

    The IMFED brand is a trademark of the Abbott Group of Companies in various jurisdictions.
    3. Please provide the following information:
    Height of child’s mother _____________ for children
    Identification and management
    of feeding difficulties
    Height of child’s father ______________
    Was the child born premature? Yes No
    If yes, how many weeks into the pregnancy was
    Do Not Write In This Section—For Office Use Only
    the child born? ________________________________
    Did either of the child’s parents experience delayed Weight-for-age percentile _____________
    puberty or slow growth as a child? Yes No Height-for-age percentile _____________
    If yes, which parent? ___________________________
    Weight-for-height _____________

    Projected height at 20 years of age if child continues


    4. Does your child eat:
    to grow along current height-for-age percentile:
    Fruits? Yes No
    If yes, which ones? ____________________________
    Midparental height calculations:
    Vegetables? Yes No Boys:
    If yes, which ones? ____________________________ (______________+______________)÷2=____________
    Dad’s height (cm) Mom’s height (cm)+13
    Meats or meat alternatives (e.g. tofu, soy beancurd,
    nuts, beans)? Yes No Girls:
    If yes, which ones? ____________________________
    (______________+______________)÷2=____________
    Dad’s height (cm) –13 Mom’s height (cm)
    Dairy products? (e.g. milk, cheese, yogurt)
    Yes No Midparental height - Projected height at 20 years
    If yes, which ones? ____________________________ = ____________________________

    Grains or other starchy foods? Yes No Is difference >5 cm? Yes No

    If yes, which ones? ____________________________

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