Parent's First Name
* Parent's First Name
Name of other parent (if applicable)
Which method of on-going correspondence works best for you during our time together?
None of the above
Which form of video chat do you prefer?
Please provide contact details for both video and text messages.
Does your child have siblings?
Did any of your other children have concerns with their feeding &/or growth?
Any history within the family of allergies?
Child's Full Name
* Child's Full Name
Date of Birth
* Date of Birth
How old is your child to date?
Was your baby preterm?
Weight at birth
Height at birth
How many weeks gestation was baby born?
How was your birth?
Did you experience complications during the birth?
Child's current weight
Child's current height
Any current diagnosed medical conditions to be aware of?
Have you consulted with other health professionals regarding the problem at hand? If so, who and what was the diagnoses?
Is your child taking any medication?
If yes, what was prescribed?
How is the medication administered?
How much medication is taken in a 24 hour period?
How long has your child been using said medication(s)?
Do you find it difficult to give the medication?
Have you experienced a positive or negative outcome from giving the medications?
Do you have any further follow-up appointments with your medical team to date?
Currently, do you see a well-nourished baby?
Any signs of illness recently? If so, type of illness?
How many wet nappies in 24 hours?
How many bowel movements in 7 days?
Do you find your child to be gassy? If so, is there signs of discomfort due to gas?
Does your child vomit daily? If so, is it a concern to you? If yes, please explain further.
Does your child have any signs skin conditions? Difficulties breathing due to coughing, sneezing, wheezing, blocked nose? If yes, please explain further.
Is your child hitting current milestones for their age?
How was your child fed at birth? (breastfed, bottle, syringe, NG tube, TPN, etc)
What was the first signs of a feeding issue?
Has your child been assessed for a safe swallow? If so, please give further details and results.
In an ideal world, how would you like to feed your child? What is our goal?
How do you currently feed your child?
Do you find feeding your child while asleep or drowsy is easier at the moment? Will they take more orally if in a drowsy state? Please give full details.
What type of milk are you currently using?
Do you feel you’d benefit from a nutritionist guiding you through solids? Would you chose this in a package if it were available?
Please skip if not applicable
How often do you breastfeed in 24 hours?
How often do you pump in 24-hours? (if any)
Do you offer both breasts? (Feed until drained, cluster feed, both breasts in one feed) Please give me a better idea of your typical feeding routine.
Are you currently seeing signs of an aversion to the breast?
Will baby fall to sleep on the breast?
Do you exclusively breastfeed? Or pump and offer bottled breastmilk and/or mixed with formula?
How do you feel your supply is currently?
How do you feel your let down is?
Are you taking any medications or herbal remedies?
Do you drink coffee or caffeinated drinks? If so, how many within 24 hours?
Are you restricting your diet in any way? If so, in what way?
Did you breastfeed other children? If so, for how long? Did you experience any troubles or concerns at the time?
Do you wish to continue to breastfeed if possible?
Please skip if not applicable.
When did you begin to offer the bottle?
Do you increase the calories currently to the bottle with any extra scoops, thickeners, cereals, oils? If so, please describe.
Please outline a rough timeline on offers within the 24 hours.
How many bottles do you offer within a 24 hour time frame?
How much does baby take within each bottle?
Do you find one offer will be better than another? (ex. morning bottles are less than the afternoon bottle)
How long does it typically take for baby to finish the bottle?
What type of bottle do you current use?
Which nipple and flow do you use?
Is the bottle or nipple vented?
Does baby fuss, cry, arch back, cough, gag or flat-out refuse bottle when you offer? Please explain your experience a little further.
At what point did you begin to see difficulty with feeding from the bottle?
Which position do you currently feed baby? (in your arms, propped on pillows, baby rocker, etc)
Do you swaddle baby during a feed?
Do you find distractions or entertainment helps you fed baby more calmly? (i.e. TV, toys, rocking, walking, etc)
Do you find yourself consistently offering the bottle to baby in order to take it and feed? How often do you say you offer the bottle in one feed?
What is your ultimate goal with the bottle at this stage?
Please skip is not applicable.
What type of feeding tube does your child have?
How long has the tube been placed?
At what age was the tube placed?
How many tube-feeds are offered in 24 hours?
How much is given through the tube within 24 hours?
Do you offer an oral feed first and then top-up the remaining with the tube?
Do you use pump or gravity feeds?
How long does the feed take?
Do you do continuous feeding overnight? If so, for how long and at what rate?
Do you have a set plan to wean your child from the tube with a feeding team currently? If so please explain.
What is your ultimate goal with the tube feeding at this stage?
Please skip if not applicable.
Are you currently offering solids?
If so, how often?
Do you offer spoon feeding and/or baby lead weaning/finger foods?
What type of foods are you offering?
Do you find your child happily accepts the solids from you? Please explain if yes or no.
What type of seat does baby sit in during feeding time?
Do you offer solids before or after a milk feed? How are the feeds typically spaced out?
Do you find distractions or entertainment help more food go in?
Does your child open their mouth for the food offered or do you just put it into their mouth typically?
How many hours sleep does your child get within 24 hours?
How many of those hours are during the day?
How many are at night?
How do you settle them to sleep? (feeding, cuddle, rocking, self-soothe, etc)
How long are naps generally?
Does your child wake in the night for a feed? If so, how many times?
Does your child wake in the night but still refuse a feed? If so, how many times?
Do you use a wedge of some sort to elevate the bed?
Do you feel your child needs a lot of support to fall to sleep and/or stay asleep?
Are you happy with the current sleeping situation or it could use some work?
Do you feel you need support on sleep as well as feeding?
Do you currently have a day-to-day routine? If so, please explain further. If not, would you like to create one?
Do you and/or your partner work? If so, how often?
Does anyone else look after your child(ren) while you are at work? If yes, who and how many days and where are they looked after? (daycare, in-house, nanny-share, etc)
Are you comfortable with the way other people feed your child?
Do you currently have regular support, both emotionally and physically?
Are you able to get away to take a break? (this could be a full day out of the house or a relaxing bath! anything that will help clear your head and take the edge off)
Is your anxiety level currently at a rate that you can manage? (I personally feel it is inevitable to have anxiety at a time like this, but understand some can suffer worse than others).
If you feel your anxiety is to hard to cope with, are you able to seek help and support with your family/friends and/or local community?
What are your hopes and goals for your child at present?
What are your hopes and goals for YOU at present?
Do you have a medical make-up from your doctor confirming an aversion?
Are you aware that Nourish Consultancy is not a medical practice and will not be able to give medical advice?
Have you read any books explaining what an aversion is and how to overcome it? If so, which book?
How did you hear about Nourish Consultancy?
Do you have an Instagram or Facebook account? If so, please include your contact details so we can add you to our support groups.
Are you comfortable with sharing a testimonial following your work with Nourish Consultancy? If yes, do you give the rights to for NC to share via social media? If yes, please send on a photo of your child for us to include in the success post!
Please include any further information you feel may be relevant that we've yet to cover here.