Please answer the following about your child’s rumination symptoms:
1. How frequently does food come up, but you are able to re-swallow or keep it down?
a. Everyday
b. Several times a day c. Once a week
d. Once every 2-3 weeks e. Once a month
f. Never
2. If every day, how many times each day?
a. 0-5 b. 5-10 c. 10+
3. How frequently do you vomit food out?
a. Everyday
b. Several times a day c. Once a week
d. Once every 2-3 weeks e. Once a month
f. Never
4. If every day, how many times each day?
a. 0-5 b. 5-10 c. 10+
5. How many meals per day do you skip?
a. Do not skip meals b. <1
c. 1 d. 2 e. 3
6. Are you getting extra nutrition through a feeding tube or IV line (parenteral nutrition or TPN)?
a. Yes b. No
7. Have you been losing weight because of vomiting?
a. Yes b. No
8. Do you feel that you/your child’s rumination symptoms have improved since starting therapy?
a. Yes b. No
c. Explain:______________________________
Due to the pandemic, we have started conducting virtual visits on the computer to allow patients to be treated for their rumination symptoms without having to be seen in person.
9. What kind of treatment experience have you or your child undergone for their rumination?
a. In person
b. Online
10. Do you think the treatment program your child completed would be better in person or online (seeing our psychologist and completing treatments through video visits)?
a. In person b. Online c. Don’t know
11. Please explain your answer to Question 10:
12. What are the strengths of doing the treatment program in person? Choose all the apply.
Examples below:
a. I think the treatment would work better in person
b. My child is more comfortable talking to someone in person c. Fewer distractions
d. Stronger connection with provider e. Other:_______________________
13. What are the challenges of doing the treatment program in person? Examples below:
a. Transportation and parking b. Takes more time
c. My child is more comfortable talking to someone online d. More distractions
e. Other:_______________________
14. What are the strengths of doing the treatment program online? Examples below:
a. I think the treatment would work better online b. Saves time
c. My child is more comfortable at home
d. My child is more comfortable talking to someone online e. Other:_______________________
15. What are the challenges of doing the treatment program online?
a. Internet connection
b. Having a computer or phone that can handle online visits c. My child is more comfortable talking to someone in person d. More distractions
e. Other:________________________
16. Which style would you have preferred for the treatment program (in person or online)?
a. In person b. Online c. Don’t know
17. Please explain your answer to Question 16.
