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Participants Name:
*
Does Participant has any special personal, cultural or religious food preferences?
Yes
No
Participants NDIS Number:
*
Participant's capacity to feed own self?
Yes - can feed ownself
Needs Supervision
Needs minimum assistance
Needs major assistance
Needs special equipment
Does Participant any food allergies?
Yes
No
List all applicable
Include any allergies, personal, cultural or religious preferences.
1. Day of the Week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Weekdays only
Weekends only
All days of the week
Meal/s of the Day
Breakfast
Lunch
Dinner
Snacks
All Three Meals
All Three Meals and Snacks
Texture
Regular Food - Easy to Chew
Soft and Bite-Sized
Minced and Moist
Pureed
Liquidised - Moderately Thick
Liquidised - Mildly Thick
Liquidised - Thin
Quantity and Unit
Small - 100gms
Medium - 200-400gms
Large - 400 gms
Portion Controlled (1/4 - 1/2)
Any fluid restrictions per day
Less than 1000 ml or 1 Litre per day
Between 1000 mls and 2000 mls (1-2L)
No Fluids Restriction
Any medications?
No relevance of food and medications.
Participant take medications before the meal.
Participant take medications after the meal.
Choice 3
Positioning of client (before/during and after feeding)
Sitting Upright
Sitting Inclined
Procedure of Preparation and Providing meals
2. Day of the Week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Weekdays only
Weekends only
All days of the week
Meal/s of the Day
Breakfast
Lunch
Dinner
Snacks
All Three Meals
All Three Meals and Snacks
Texture
Regular Food - Easy to Chew
Soft and Bite-Sized
Minced and Moist
Pureed
Liquidised - Moderately Thick
Liquidised - Mildly Thick
Liquidised - Thin
Quantity and Unit
Small - 100gms
Medium - 200-400gms
Large - 400 gms
Portion Controlled (1/4 - 1/2)
Any fluid restrictions per day
Less than 1000 ml or 1 Litre per day
Between 1000 mls and 2000 mls (1-2L)
No Fluids Restriction
Any medications?
No relevance of food and medications.
Participant take medications before the meal.
Participant take medications after the meal.
Choice 3
Positioning of client (before/during and after feeding)
Sitting Upright
Sitting Inclined
Procedure of Preparation and Providing meals
3. Day of the Week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Weekdays only
Weekends only
All days of the week
Meal/s of the Day
Breakfast
Lunch
Dinner
Snacks
All Three Meals
All Three Meals and Snacks
Texture
Regular Food - Easy to Chew
Soft and Bite-Sized
Minced and Moist
Pureed
Liquidised - Moderately Thick
Liquidised - Mildly Thick
Liquidised - Thin
Quantity and Unit
Small - 100gms
Medium - 200-400gms
Large - 400 gms
Portion Controlled (1/4 - 1/2)
Any fluid restrictions per day
Less than 1000 ml or 1 Litre per day
Between 1000 mls and 2000 mls (1-2L)
No Fluids Restriction
Any medications?
No relevance of food and medications.
Participant take medications before the meal.
Participant take medications after the meal.
Choice 3
Positioning of client (before/during and after feeding)
Sitting Upright
Sitting Inclined
Procedure of Preparation and Providing meals
4. Day of the Week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Weekdays only
Weekends only
All days of the week
Meal/s of the Day
Breakfast
Lunch
Dinner
Snacks
All Three Meals
All Three Meals and Snacks
Texture
Regular Food - Easy to Chew
Soft and Bite-Sized
Minced and Moist
Pureed
Liquidised - Moderately Thick
Liquidised - Mildly Thick
Liquidised - Thin
Quantity and Unit
Small - 100gms
Medium - 200-400gms
Large - 400 gms
Portion Controlled (1/4 - 1/2)
Any fluid restrictions per day
Less than 1000 ml or 1 Litre per day
Between 1000 mls and 2000 mls (1-2L)
No Fluids Restriction
Any medications?
No relevance of food and medications.
Participant take medications before the meal.
Participant take medications after the meal.
Choice 3
Positioning of client (before/during and after feeding)
Sitting Upright
Sitting Inclined
Procedure of Preparation and Providing meals
5. Day of the Week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Weekdays only
Weekends only
All days of the week
Meal/s of the Day
Breakfast
Lunch
Dinner
Snacks
All Three Meals
All Three Meals and Snacks
Texture
Regular Food - Easy to Chew
Soft and Bite-Sized
Minced and Moist
Pureed
Liquidised - Moderately Thick
Liquidised - Mildly Thick
Liquidised - Thin
Quantity and Unit
Small - 100gms
Medium - 200-400gms
Large - 400 gms
Portion Controlled (1/4 - 1/2)
Any fluid restrictions per day
Less than 1000 ml or 1 Litre per day
Between 1000 mls and 2000 mls (1-2L)
No Fluids Restriction
Any medications?
No relevance of food and medications.
Participant take medications before the meal.
Participant take medications after the meal.
Choice 3
Positioning of client (before/during and after feeding)
Sitting Upright
Sitting Inclined
Procedure of Preparation and Providing meals
6. Day of the Week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Weekdays only
Weekends only
All days of the week
Meal/s of the Day
Breakfast
Lunch
Dinner
Snacks
All Three Meals
All Three Meals and Snacks
Texture
Regular Food - Easy to Chew
Soft and Bite-Sized
Minced and Moist
Pureed
Liquidised - Moderately Thick
Liquidised - Mildly Thick
Liquidised - Thin
Quantity and Unit
Small - 100gms
Medium - 200-400gms
Large - 400 gms
Portion Controlled (1/4 - 1/2)
Any fluid restrictions per day
Less than 1000 ml or 1 Litre per day
Between 1000 mls and 2000 mls (1-2L)
No Fluids Restriction
Any medications?
No relevance of food and medications.
Participant take medications before the meal.
Participant take medications after the meal.
Choice 3
Positioning of client (before/during and after feeding)
Sitting Upright
Sitting Inclined
Procedure of Preparation and Providing meals
7. Day of the Week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Weekdays only
Weekends only
All days of the week
Meal/s of the Day
Breakfast
Lunch
Dinner
Snacks
All Three Meals
All Three Meals and Snacks
Texture
Regular Food - Easy to Chew
Soft and Bite-Sized
Minced and Moist
Pureed
Liquidised - Moderately Thick
Liquidised - Mildly Thick
Liquidised - Thin
Quantity and Unit
Small - 100gms
Medium - 200-400gms
Large - 400 gms
Portion Controlled (1/4 - 1/2)
Any fluid restrictions per day
Less than 1000 ml or 1 Litre per day
Between 1000 mls and 2000 mls (1-2L)
No Fluids Restriction
Any medications?
No relevance of food and medications.
Participant take medications before the meal.
Participant take medications after the meal.
Choice 3
Positioning of client (before/during and after feeding)
Sitting Upright
Sitting Inclined
Procedure of Preparation and Providing meals
Note:
Submit
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