* Parent/Guardian Name
Country, Postal Code
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
Has your child been able to maintain a steady growth curve with tube feeds, at any percentile?
Current known allergies:
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?
Please list what you put in your child's tube, how much you put, and what times you feed.
If bolus feeds, how are they delivered and how fast? (ie, syringe or pump or gravity and in how many minutes)
If continuous, how many consecutive hours at a time are they running, or for how many minutes if feeds run longer than 1 hour?
Does your child have current issues with reflux or constipation? If so, how is it managed?
Does your child have any difficulties with tube feed toleration? If so, please list. Provide as much detail as you can.
e.g. granulation, rash, frequent removals or changing, vomit, retching, etc.
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:
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?
Therapy Experience (if any)
What did you find most helpful?
What did you find least helpful?
Is your child receiving any developmental therapy? If so, what is it targeting?
Give us a snapshot of your child's overall development in this moment.
Has anyone ever told you your child may be on the autism spectrum? If so, please provide specifics.
Has anyone told you your child might have sensory processing disorder? If so, please provide specifics.
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.
What do you hope for your child at this time?
What do you hope to learn from this consultation program?
Is there anything else we need to know?
How did you hear about GIE?