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Feeding Forms

Please call us at (585) 275-2986 to discuss our feeding program for your child. If your child is appropriate, we will schedule an appointment and ask you to complete the following paperwork.

Please bring this paperwork to your child's appointment!

  • New Patient Questionnaire - This questionnaire is a chance for us to learn about your child before your visit. It should be completed by the person who takes care of your child most of the time. This will help us to make the visit go smoothly. There are no right or wrong answers. Answer each question to the best of your ability.
  • Returning Patient Questionnaire - This is a questionnaire that gathers detailed information about your child’s feeding history, food preferences, and current mealtime routines.
  • 3-Day Food Record - We ask you to keep track of everything that your child eats and drinks for 3 days. Please be sure to review the instructions on the front of the form.
  • 3-Day Food Record (Spanish) Trastornos Alimenticios – Diario de 3 días consecutivos - Le pedimos que lleve un registro de todo lo que come y bebe su hijo durante 3 días. Asegúrese de revisar las instrucciones al frente del formulario.

We look forward to working with you and your child. If you have any questions, please feel free to call us at (585) 275-2986.