{"product_id":"pediatric-feeding-evaluation-template","title":"Comprehensive Pediatric Feeding Evaluation Template","description":"\u003cp\u003e\u003cstrong\u003eA fillable pediatric feeding evaluation, birth to 18, that collects every piece of evidence a payer looks for.\u003c\/strong\u003e\u003c\/p\u003e\n\u003cp\u003eBuilt by Meagan Dungan, M.S., CCC-SLP, this 21-page fillable PDF takes you from referral and orders to a signed plan of care. Its 17 sections match the Gold Standard Pediatric Feeding Evaluation Report Guide, so you can gather the evidence here and write the report with the guide open beside it.\u003c\/p\u003e\n\u003ch3\u003eNew: special situations built in\u003c\/h3\u003e\n\u003cp\u003eTube feeding and weaning readiness, breastfeeding and IBCLC coordination, saliva management and oral hygiene, pulse oximetry and cervical auscultation, telehealth, interpreters and family food culture, plus late entry and addendum fields, all placed in the matching sections.\u003c\/p\u003e\n\u003ch3\u003e5 referral decision guides\u003c\/h3\u003e\n\u003cp\u003eYes\/no flowcharts that walk you to the right next step, color-coded by urgency:\u003c\/p\u003e\n\u003cul\u003e\n\u003cli\u003eA. Instrumental swallow study (VFSS or FEES)\u003c\/li\u003e\n\u003cli\u003eB. Physician, GI and dietitian\u003c\/li\u003e\n\u003cli\u003eC. ENT, airway and sleep\u003c\/li\u003e\n\u003cli\u003eD. Tethered oral tissue: release assessment\u003c\/li\u003e\n\u003cli\u003eE. Psychology, development and family support\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003ch3\u003eSections\u003c\/h3\u003e\n\u003col\u003e\n\u003cli\u003eIdentifying information, referral and orders (payer, order type, THSteps, prior authorization, telehealth, interpreter and family food culture)\u003c\/li\u003e\n\u003cli\u003eBirth and medical history, growth, hydration, safety events, prior swallow studies\u003c\/li\u003e\n\u003cli\u003eDevelopmental history and services, with an ECI and school coordination statement\u003c\/li\u003e\n\u003cli\u003eFeeding history and current intake, including breastfeeding and tube feeding\u003c\/li\u003e\n\u003cli\u003eOral mechanism examination, including saliva management and oral hygiene\u003c\/li\u003e\n\u003cli\u003eFunctional assessment of tethered oral tissues\u003c\/li\u003e\n\u003cli\u003eBreathing and airway\u003c\/li\u003e\n\u003cli\u003ePosture, positioning and motor\u003c\/li\u003e\n\u003cli\u003eSensory, behavior and caregiver interaction\u003c\/li\u003e\n\u003cli\u003eClinical feeding observation and trials, with supplemental monitoring and a trial comparison table\u003c\/li\u003e\n\u003cli\u003eStandardized and validated tools (Feeding Flock rows plus MCH-FS, BPFAS, PEDI-EAT-10, TOMASS-C and a drooling scale)\u003c\/li\u003e\n\u003cli\u003eClinical impressions and diagnosis, with PFD criteria and ICD-10 coding\u003c\/li\u003e\n\u003cli\u003eReferrals and instrumental assessment, with red flags and same-day physician contact\u003c\/li\u003e\n\u003cli\u003eRecommendations\u003c\/li\u003e\n\u003cli\u003eMedical necessity and functional impact\u003c\/li\u003e\n\u003cli\u003ePlan of care and goals, with a WHY + HOW + WHAT goal table that links each goal to the deficit and section it came from, plus frequency rationale, step-down plan, home program and discharge criteria\u003c\/li\u003e\n\u003cli\u003eSignatures and attestations, with record integrity fields\u003c\/li\u003e\n\u003c\/ol\u003e\n\u003ch3\u003ePairs with\u003c\/h3\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/pediatric-feeding-evaluation-report-writing-guide\"\u003eGold Standard Pediatric Feeding Evaluation Report Guide\u003c\/a\u003e ($47): turn this evaluation into a report, plan of care and appeal letters, with 3 annotated sample reports.\u003c\/li\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/pediatric-feeding-myofunctional-therapy-goal-bank\"\u003ePediatric Feeding \u0026amp; Myofunctional Goal Bank\u003c\/a\u003e ($35): 303 SMART goals in the same WHY + HOW + WHAT format, with sample goal sets for common caseloads, as a PDF and a filterable spreadsheet.\u003c\/li\u003e\n\u003cli\u003eSave with the \u003ca href=\"\/products\/feeding-evaluation-report-bundle\"\u003eEvaluation + Report Bundle\u003c\/a\u003e ($55) or the \u003ca href=\"\/products\/complete-feeding-documentation-set\"\u003eComplete Feeding Documentation Set\u003c\/a\u003e ($85).\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003ch3\u003eMore from NTX: tethered oral tissues\u003c\/h3\u003e\n\u003cp\u003eFor tethered oral tissues, NTX also offers specialized evaluations and protocols. Browse every resource on the \u003ca href=\"\/collections\/therapist-education\"\u003eTherapist Resources\u003c\/a\u003e page.\u003c\/p\u003e\n\u003cp\u003e\u003cstrong\u003eMyofunctional (ages 2 and up)\u003c\/strong\u003e\u003c\/p\u003e\u003cul\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/myofunctional-evaluation-template\"\u003ePediatric Myofunctional Evaluation Template\u003c\/a\u003e ($19): fillable tethered oral tissue evaluation for ages 2 and up: speech, feeding and airway.\u003c\/li\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/myofunctional-therapy-protocol\"\u003eMyofunctional Therapy Protocol for Tethered Oral Tissues (3 Editions)\u003c\/a\u003e ($97): pre-release to discharge, 14 exercises, in 3 kid-friendly editions.\u003c\/li\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/myofunctional-evaluation-protocol-bundle\"\u003eMyofunctional Evaluation + Protocol Bundle\u003c\/a\u003e ($105): the myofunctional evaluation template and the 3-edition protocol.\u003c\/li\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/complete-myofunctional-set\"\u003eComplete Myofunctional Set\u003c\/a\u003e ($135): myofunctional evaluation template, 3-edition protocol and goal bank.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003e\u003cstrong\u003eOral motor (birth to about 2)\u003c\/strong\u003e\u003c\/p\u003e\u003cul\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/oral-motor-evaluation-template\"\u003ePediatric Oral Motor Evaluation Template\u003c\/a\u003e ($19): fillable tethered oral tissue evaluation for birth to about 2: feeding, airway and pre-speech.\u003c\/li\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/tiny-tongues-infant-oral-motor-protocol\"\u003eTiny Tongues Infant Oral Motor Protocol\u003c\/a\u003e ($97): therapist-provided oral motor protocol for infants and young toddlers, with a parent home routine.\u003c\/li\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/oral-motor-evaluation-protocol-bundle\"\u003eOral Motor Evaluation + Protocol Bundle\u003c\/a\u003e ($105): the oral motor evaluation template and the Tiny Tongues protocol.\u003c\/li\u003e\n\u003cli\u003e\n\u003ca href=\"\/products\/complete-oral-motor-set\"\u003eComplete Oral Motor Set\u003c\/a\u003e ($135): oral motor evaluation template, Tiny Tongues protocol and goal bank.\u003c\/li\u003e\n\u003c\/ul\u003e\n\u003cp\u003eInstant PDF download. Fill it on screen or print it. Single-clinician license.\u003c\/p\u003e","brand":"NTX Feeding \u0026 Myofunctional Therapy Institute","offers":[{"title":"Default Title","offer_id":44604005023822,"sku":null,"price":15.0,"currency_code":"USD","in_stock":true}],"thumbnail_url":"\/\/cdn.shopify.com\/s\/files\/1\/0768\/0458\/7598\/files\/NTX-Eval-Template-Cover-v3_b5a3b7cc-828a-4e4e-a586-2b9fcc73a6d9.png?v=1792437658","url":"https:\/\/ntxfeedingandmyo.com\/products\/pediatric-feeding-evaluation-template","provider":"NTX Feeding \u0026 Myofunctional Therapy Institute","version":"1.0","type":"link"}