Name *

First Name

Last Name

Age of person with a feeding tube or infusion port *

<1 year

1-5 years

6-10 years

11-18 years

19-35 years

36-65 years

>65 years

How long have you or your loved one, had a feeding tube or port? *

<1 year

1-5 years

6-10 years

>10 years

Check all that you currently use *

G-tube, J-tube, GJ-tube

NG-tube or NJ-tube

Infusion port

Other (please explain)

Check all that you currently use *

Pump feeds

Gravity syringe feeds

Push syringe feeds

Gravity bag feeds

Infusions

Other (please explain)

1. When I (or my loved one), first received a feeding tube or port, I was confident in feeding or administering an infusion outside of the hospital or doctor’s office. *

Agree

Strongly agree

Disagree

Strongly disagree

2. Since having my feeding tube or port or caring for my loved one with a feeding tube or port, I am confident in leaving home for a fun overnight or weeklong stay? (Example: vacation, overnight trip to visit family and friends, etc.) *

Agree

Strongly agree

Disagree

Strongly disagree

3. If pump feeding or administering infusions, what do you do currently when you need to leave the house for a doctor appointment or other activity? *

Use a backpack

Take an IV pole

Skip feeding

Leave the house during non-feed or non-infusion times

Other (please explain)

4. If pump feeding or administering infusions, where do you feed/infuse inside your home? *

Move IV pole around the house to pump feed or administer infusions in different rooms.

Pump feed or administer infusions in the same room every day using an IV pole.

Use a backpack.

Other (please explain)

5. How often do you need to tube feed or administer an infusion while away from home? *

Often

Somewhat often

Somewhat never

Never

6. When holding a syringe for feeding, how often does vomiting or spitting up occur? *

Often

Somewhat often

Somewhat never

Never

N/A

7. If syringe feeding, what do you do when you need to leave the house for a doctor appointment or other activity? *

Hold syringe in my hand

Skip feeding

Leave the house during non-feed times

Other (please explain)

N/A

8. If syringe feeding, how often are you able to perform therapies while holding the syringe? (For example: working on stretches or exercises, holding a pacifier in for a child with a feeding tube) *

Often

Somewhat often

Somewhat never

Never

N/A

9. If syringe feeding, how often are you able to do other activities while holding the syringe? (For example: read or look at your phone for adults or read to your child with a feeding tube) *

Often

Somewhat often

Somewhat never

Never

N/A

10. If syringe feeding, how often do you spill a feed or medicine bolus? *

Often

Somewhat often

Somewhat never

Never

N/A

11. Since having a feeding tube or port, how often have you been readmitted to the hospital for feeding or infusion issues? *

1-3 times per month

4-7 times per month

8-10 times per month

>10 times per month

Never

13. If gravity syringe feeding, how were you instructed? Check all that apply. *

Hang syringe with string over bed

Hold syringe in hand

Tape or rubber band syringe to another object (IV pole, bed, wall, shirt, etc)

Other (please explain)

14. If gravity syringe feeding, how do you currently administer feeds while inside your home? Check all that apply. *

Hang syringe with string over bed

Hold syringe in hand

Tape or rubber band syringe to another object (IV pole, bed, wall, shirt, etc)

Other (please explain)