Title: Assessment of a Five-Year-Old’s Eating Habits and Oral Motor Function

Instructions: This assessment is designed to evaluate a five-year-old child’s eating habits, including their likes, dislikes, and observations related to oral motor function. Please answer the following questions to the best of your ability, based on your observations and interactions with the child.

Child’s Name: ________ Date: ________

Section 1: Eating Habits

1. What are the child’s favorite foods? Please list at least three. a. ________ b. ________ c. ________

2. What are the child’s least favorite foods? Please list at least three. a. ________ b. ________ c. ________

3. Does the child have any specific dietary restrictions or allergies? If yes, please specify. ________

4. How would you describe the child’s appetite? (e.g., small, average, large) ________

5. Does the child eat a variety of foods from different food groups? Please provide examples. ________

Section 2: Oral Motor Function

1. Does the child have any difficulty with chewing or swallowing? If yes, please describe. ________

2. How would you rate the child’s ability to use utensils (e.g., spoon, fork) during meals? a. Independent b. Requires assistance c. Unable to use utensils

3. Does the child exhibit any oral motor difficulties, such as drooling or difficulty with lip closure? If yes, please describe. ________

4. Does the child have any difficulty with biting or chewing certain textures? If yes, please describe. ________

5. Does the child engage in any oral habits during meals (e.g., sucking fingers, chewing on objects)? If yes, please describe. ________

Section 3: General Observations

1. How long does the child typically take to finish a meal? ________

2. Does the child show interest in trying new foods? If yes, please provide examples. ________

3. Does the child exhibit any behaviors related to food aversion or refusal? If yes, please describe. ________

4. Does the child display any signs of discomfort or pain while eating? If yes, please describe. ________

5. Are there any other observations or concerns related to the child’s eating habits or oral motor function that you would like to note? ________

Thank you for completing this assessment. Your input will help us better understand the child’s eating habits and oral motor function.