Mealtime Management Form

Please complete the form below. A member of the Care Zone team will review your submission.

Fields marked * are required.

Step 1 of 6

Step 1

MEALTIME MANAGEMENT PLAN

NOTE 1:

Please read the details on this form and check the labels of the meals carefully. Please follow the instructions on the meal label for safe and secure storage. Please report all incidents, issues, and concerns as soon as possible.

NOTE 2:

A copy of this form should be kept by the support worker and another copy should be provided to the participant.

Participants Name:*

Phone Number*

Does Participant has any special personal, cultural or religious food preferences?

Yes No

Participants NDIS Number:*

Participant's capacity to feed own self?

Does Participant any food allergies?

Yes No

Service Start Date*

Address*

List below the Foods that should not be provided to the participant for any reason such as swallowing difficulties, diabetes, anaphylaxis, food allergies, obesity, and/or being underweight, etc.:

List all applicable

Include any allergies, personal, cultural or religious preferences.

1. Day of the Week

Meal/s of the Day

Time to be served

Texture

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Step 2

Quantity and Unit

Any fluid restrictions per day

Any medications?

Positioning of client (before/during and after feeding)

Procedure of Preparation and Providing meals

2. Day of the Week

Meal/s of the Day

Time to be served

Texture

Quantity and Unit

Any fluid restrictions per day

Any medications?

Positioning of client (before/during and after feeding)

Step 3 of 6

Step 3

Procedure of Preparation and Providing meals

3. Day of the Week

Meal/s of the Day

Time to be served

Texture

Quantity and Unit

Any fluid restrictions per day

Any medications?

Positioning of client (before/during and after feeding)

Procedure of Preparation and Providing meals

4. Day of the Week

Meal/s of the Day

Time to be served

Step 4 of 6

Step 4

Texture

Quantity and Unit

Any fluid restrictions per day

Any medications?

Positioning of client (before/during and after feeding)

Procedure of Preparation and Providing meals

5. Day of the Week

Meal/s of the Day

Time to be served

Texture

Quantity and Unit

Any fluid restrictions per day

Any medications?

Step 5 of 6

Step 5

Positioning of client (before/during and after feeding)

Procedure of Preparation and Providing meals

6. Day of the Week

Meal/s of the Day

Time to be served

Texture

Quantity and Unit

Any fluid restrictions per day

Any medications?

Positioning of client (before/during and after feeding)

Procedure of Preparation and Providing meals

7. Day of the Week

Meal/s of the Day

Step 6 of 6

Step 6

Time to be served

Texture

Quantity and Unit

Any fluid restrictions per day

Any medications?

Positioning of client (before/during and after feeding)

Procedure of Preparation and Providing meals

Note:

Your responses are submitted securely and stored in Care Zone's confidential records.