n e w j e r s e y p e d i a t r i c f e e d i n g a s s o c i a t e s, l l c（n e w j e r s e y p e d我t r c f e e d n g s s o c i t e s l l c）.docVIP

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n e w j e r s e y p e d i a t r i c f e e d i n g a s s o c i a t e s, l l c（n e w j e r s e y p e d我t r c f e e d n g s s o c i t e s l l c）.doc

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n e w j e r s e y p e d i a t r i c f e e d i n g a s s o c i a t e s, l l c（n e w j e r s e y p e d我t r c f e e d n g s s o c i t e s l l c）

150C Tices Lane East Brunswick, NJ 08816 (732) 698-1100 Fax (732) 698-1140 Feeding/Swallowing Evaluation Intake Patient Information Name of child:_______________________ Date of Birth:________________ Address:_____________________________________________________________ Telephone: (___)____________________ Cell phone: ( )_____________ Name of parent/caregiver:________________________________________________ Physician:________________________________ Telephone: ( )______________ Address:______________________________________________________________ Date of evaluation:______________________________________________________ Medical History Where there any problems during your pregnancy?_____________________________ Did you take any medications/drugs during your pregnancy?______________________ Length of Pregnancy:_____________ Delivery method:____________________ How long was your child in the hospital?_____________________________________ Where there any complications during your delivery? If so, please explain.__________ _______________________________________________________________________________________________________________________________________________. Where there any complications following your delivery? If so, please explain________ _______________________________________________________________________ _______________________________________________________________________. Was your child ever fed by a tube, either nasogastric or gastrostomy?_______________ Any additional information that you feel may be important for this evaluation_________ ________________________________________________________________________________________________________________________________________________ Is your child taking any medications at this time? If yes, please explain______________ ________________________________________________________________________ Has your child been diagnosed with a medical c