1

Developed by State-wide Occupational Therapy Committee, July, 2009

Iowa Occupational Therapy Evaluation Guide

Feeding/Oral-Motor Skills

Name: ______Birth Date: ______

Parent: ______Phone: ______

Teacher: ______School District: ______Building: ______

Occupational Therapist: ______Date Consent Received:______

Part I: Record Review

Significant Information (e.g. medical diagnosis, related health issues, major surgeries/hospitalizations, current medications, recent weight loss or gain, medical tests, significant birth or labor history):

Part II: Interviews

Person(s)Interviewed:______Date(s):______

Areas of Occupational Performance / Summary of performance within the educational program and activities
Activities of Daily Living
(self-help, sleep, and living skills)
Education
Work
Play & Leisure
Social Participation

Part II: Interviews--continued

Person(s)Interviewed: ______Date(s):______

Establishing the concern: Document the concerns and interventions that currently exist.

1. What is your concern about the child’s eating/feeding? How do you feel about mealtimes with your child? Does your child have any diagnosis? Does your child take any medications?
2. What have you tried? What is the outcome?
3. Describe your typical 24-hour day? (ex. Duration, amounts/foods, eating, seating, environment, behavior)
4. Describe some of the child’s strengths and preferences in this are.

A. Establishing current feeding practices:

Performance / Comments
1. How does the child presently receive nutrition? Is nutrition a concern? / (e.g., bottle, breast, g-tube, ng-tube)
2. What types of foods/liquids does the child receive by mouth and how often? Formula? Recent changes? / Pureed, junior foods, fork mashed/chopped, ground and table foods
Thin, nectar, thickened, shakes
3. Does child eat food from each group? (dairy, meats, veg, fruit, carbs/grain)
NOTE: takes 8-15 opp. to accept foods
4. Are temperatures, textures, tastes and other factors interfering?
5. How long does it take for the child to complete a meal?
6. Does child self-feed? Cupdrink?
7. Does child choke? Gag? Vomit? Spit-up? Drool? Sound congested or gurgly after eating?
8. How does child express hunger? Thirst? Full?
9. Describe your child’s typical bowel movements? Urination?

Part III: Observations

Settings Observed:______Dates:______

As you observe the child, write notes under the comment section. Place a check in the small box if there are concerns in this area.

AREA / COMMENTS
Natural Oral stimulation
(e.g., mouthing)
Positioning
Equipment used
Liquid & Food textures
Environment (physical)
Social interactions
Eating skills (e.g., oral-motor, self-feeding)
Drinking skills
Motor development (e.g. trunk rotation, hand skills)
Disengagement cues (turns away, close mouth, falls asleep, pushes food/bottle out of mouth)
Signals of fatigue/distress (changes in: color, breathing, tone, alertness)
Feeding behavior (e.g., speed, interactions, child’s cues/strategies used
Typical food intake (list meals)

Part IV: Test Information

Tests/Tools Used / Date Administered / Results
Current height and weight / Height: ______Weight: ______
Ratio: ______BMI: ______
Peach Survey
Morris Pre-Feeding Checklist / Strengths:
Delays:

Part V: Problem Analysis:

Complete this form using the data you have gathered.

Supports / Barriers/Limitations
Instruction:
What strategies need to be used in teaching?
Curriculum:
What does child need to learn?
Environment:
What accommodations, program modifications and assistive technology needed for child to learn?
Learner
What characteristics of the child support or interfere with learning?

ADDITIONAL NOTES: