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Infant and Child Feeding Questionnaire Screening Tool

(Traumatic, Anoxia)

Pediatric Feeding Disorders

Infant and Child Feeding Questionnaire Screening Tool

Infant and Child Feeding Questionnaire Screening Tool

"*" indicates required fields

Parent First Name*

Parent Last Name*

Email*

Phone*

Child's First Name*

Child's Last Name*

Child's Date of Birth*

DD slash MM slash YYYY

Birth date*

DD slash MM slash YYYY

6 question subset

Does your baby/child let you know when he is hungry?*

Yes

No

Do you think your baby/child eats enough?*

Yes

No

How many minutes does it usually take to feed your baby/child?*

<5

5-30

>30

Do you have to do anything special to help your baby/child eat?*

Yes

No

Does your baby/child let you know when he is full?*

Yes

No

Based on the questions above, do you have concerns about your baby/child's feeding?*

Yes

No

Red flag answers are in orange. If two or more of your answers are orange please contact your pediatrician

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Email

This field is for validation purposes and should be left unchanged.

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