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pulls back and refuses to continue Is withdrawn and irritable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? ____________________________