* Parent/Guardian Name
Best Time to Contact
* Child's Name
Child's Date of Birth
* Child's Date of Birth
Child's Weight at Birth
Child's Current Height
Child's Current Weight
How was your child fed at birth?
What was the first sign of eating issues?
What medical conditions, if any, was your child diagnosed with?
How old was your child when the initial tube was placed?
What kind of tube was it?
What was the reason for tube placement?
What tube do you have now?
What was your reaction to the need for tube feeding?
How many ounces or mL does your child get via tube per day?
If known, how many calories per ounce or per 100mL?
What is your mealtime tube-feeding schedule (times, amounts, form of food via tube)
What times are bolus meals, if any?
How many hours do you use continuous feeds, if at all?
How are bolus feeds given?
How large are bolus feeds?
How long does each bolus feed take?
What are you feeding?
Where do you tube feed?
If yes, please describe
Does this distress happen at a certain point during the feed?
How do you react if your child says “no” to a feed?
Are there any other reactions you want to share?
Please list any issues you and your child are having with tube-feedings and tube use.
If yes, what study was performed?
When was it performed?
What where the results?
If yes, how was the experience for both you and your child? Please describe.
If your child ate before the tube, how did his/her eating change after the tube?
If yes, please list foods and quantity:
Where does your child eat orally?
Do you use rewards, distractions to encourage eating?
What are your child’s favorite foods or drinks?
Is there a texture your child prefers?
Is there a texture your child does not like?
Do you feel you know what your child’s “yes”, “no”, “more”, cues are around feeding?
What is your mood around mealtime?
Food Experience (if your child does not eat orally right now)
Is there anything he or she will taste?
Therapy Experience (if any)
What did you find most helpful?
What did you find least helpful?
We know that tube-feeding can be a “normal” experience or a highly stressful one. In this section, we are asking how tube-feeding is impacting your life, and any specific concerns that you have.
How does the tube affect your stress levels?
What do you hope for your child at this time?
What do you hope to learn from this consultation program?
How did you hear about GIE?