Feeding Self Screening Tool – Creative Speech Therapy NYC

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Services
About
- Our Story
- Our Team
- Location
- FAQ
Testimonials
Book an Appointment
Events
Resources

Feeding Self-Screener

Please fill out the questions that apply to your child and we will be in touch with you within 24 hours.

How old is your child?

I think my child needs help with:

Picky eating
Tongue-tie (tethered oral tissue)
Open mouth posture at rest
Breast or bottle feeding
Transitioning to solid foods
G-tube feeding

Does your child have trouble latching?

Yes
No
Sometimes

Are mealtimes often unpleasant because your baby is colicky or gassy?

Yes
No
Sometimes

Does your child self-feed?

Yes
No
Sometimes

Does your child eat 10 or less specific foods?

Yes
No, they eat more than 10

Does your child take more than 30 minutes to complete a meal?

Yes
No
Sometimes

Is there an entire food your child won't eat/have stopped eating, like vegetables?

Yes
No
Sometimes

Does your child limit their food by texture i.e. chewy foods like meat or vegetables?

Yes
No
Sometimes

When your child stops eating a food, like bread, is it gone from their diet forever?

Yes
No
Sometimes

Does feeding your child feel a lot harder than for other parents you know?

Yes
No
Sometimes

Are mealtimes stressful?

Yes
No
Sometimes

an minutes your

Does your child need to be entertained while eating?

Yes
No
Sometimes

Does your child exhibit phsyical symptoms such as gagging, burping, sneezing, coughing, gas, drooling, or watery eyes when eating?

Yes
No
Sometimes

Does your child have an autism diagnosis or another disorder or syndrome?

Yes, autism
Yes, a syndrome/disorder
Yes, autism + another syndrome/disorder
No

Do you notice your child's jaw hanging open when they're resting or that they often breathe through their mouth?

Yes
No
Sometimes

When your child smiles, do you see a significant amount of their gums and not just teeth?

Yes
No

Does your child exhibit any of the following:

Messy eating
Dental problems
Fatigue from chewing
Inefficient chewing (bites that are too big)
Difficulty swallowing pills
Excessive drooling
Digestive problems
Sleep apnea
Snoring
Asthma
Chronic stuffy nose/cold
Food texture aversion
Tooth grinding
Pocketing food in the cheeks when eating
Asymmetric smile
Headaches or TMJ

Name *

Email *

Phone Number

How you heard about us

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313 East 95th Street
New York, NY 10128
Main Office Line: +1 (646) 476 - 4599
Mobile Line: (347) 926 - 3631
office@cst-nyc.com

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