Comprehensive Pediatric Feeding Evaluation Template

A fillable pediatric feeding evaluation, birth to 18, that collects every piece of evidence a payer looks for.

Built 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.

New: special situations built in

Tube 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.

5 referral decision guides

Yes/no flowcharts that walk you to the right next step, color-coded by urgency:

• A. Instrumental swallow study (VFSS or FEES)
• B. Physician, GI and dietitian
• C. ENT, airway and sleep
• D. Tethered oral tissue: release assessment
• E. Psychology, development and family support

Sections

1. Identifying information, referral and orders (payer, order type, THSteps, prior authorization, telehealth, interpreter and family food culture)
2. Birth and medical history, growth, hydration, safety events, prior swallow studies
3. Developmental history and services, with an ECI and school coordination statement
4. Feeding history and current intake, including breastfeeding and tube feeding
5. Oral mechanism examination, including saliva management and oral hygiene
6. Functional assessment of tethered oral tissues
7. Breathing and airway
8. Posture, positioning and motor
9. Sensory, behavior and caregiver interaction
10. Clinical feeding observation and trials, with supplemental monitoring and a trial comparison table
11. Standardized and validated tools (Feeding Flock rows plus MCH-FS, BPFAS, PEDI-EAT-10, TOMASS-C and a drooling scale)
12. Clinical impressions and diagnosis, with PFD criteria and ICD-10 coding
13. Referrals and instrumental assessment, with red flags and same-day physician contact
14. Recommendations
15. Medical necessity and functional impact
16. Plan 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
17. Signatures and attestations, with record integrity fields

Pairs with

• Gold Standard Pediatric Feeding Evaluation Report Guide ($47): turn this evaluation into a report, plan of care and appeal letters, with 3 annotated sample reports.
• Pediatric Feeding & Myofunctional Goal Bank ($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.
• Save with the Evaluation + Report Bundle ($55) or the Complete Feeding Documentation Set ($85).

More from NTX: tethered oral tissues

For tethered oral tissues, NTX also offers specialized evaluations and protocols. Browse every resource on the Therapist Resources page.

Myofunctional (ages 2 and up)

• Pediatric Myofunctional Evaluation Template ($19): fillable tethered oral tissue evaluation for ages 2 and up: speech, feeding and airway.
• Myofunctional Therapy Protocol for Tethered Oral Tissues (3 Editions) ($97): pre-release to discharge, 14 exercises, in 3 kid-friendly editions.
• Myofunctional Evaluation + Protocol Bundle ($105): the myofunctional evaluation template and the 3-edition protocol.
• Complete Myofunctional Set ($135): myofunctional evaluation template, 3-edition protocol and goal bank.

Oral motor (birth to about 2)

• Pediatric Oral Motor Evaluation Template ($19): fillable tethered oral tissue evaluation for birth to about 2: feeding, airway and pre-speech.
• Tiny Tongues Infant Oral Motor Protocol ($97): therapist-provided oral motor protocol for infants and young toddlers, with a parent home routine.
• Oral Motor Evaluation + Protocol Bundle ($105): the oral motor evaluation template and the Tiny Tongues protocol.
• Complete Oral Motor Set ($135): oral motor evaluation template, Tiny Tongues protocol and goal bank.

Instant PDF download. Fill it on screen or print it. Single-clinician license.