Dietary/Meals Choking Risk - Yes, No Teeth - Natural, Natural Poor Repair/Teeth Missing, Dentures, Edentulous – Yes, No Is there a history of polydipsia/excessive fluid intake - Current Physician Ordered Diet: Independent, Set-up Assistance Required, Requires Prompts, Requires Encouragement, Client must be fed by staff, Tube Feeding, Eating Requires special utensils, Requires special positioning/unique instructions Describe protocol, concerns and precautions Independent, Requires prompting/reminders, Requires assistance, Requires special cup or Requires special positioning/unique Drinking instructions, Tube feeding Describe protocol, concerns and precautions Independently and safely prepares meals requiring cooking Independently and safely prepares basic meals not requiring cooking Requires assistance with meal planning/making healthy Meal choices Requires assistance when cooking Requires assistance to prepare simple meals Totally Dependent on staff for meal preparation Food Likes Food Dislikes Comments: Toileting Continent, Occasional Incontinence, Incontinent, Wears Depends, Bladder Catheter, Urostomy, Describe protocols, concerns, precautions Continent, Occasional Incontinence, Incontinent, Wears Depends Bowel Ileostomy, Colostomy, Describe protocols, concerns, precautions
Choking Risk - Yes, No Dietary/Meals Teeth - Natural, Natural – Poor Repair/Teeth Missing, Dentures, Edentulous Is there a history of polydipsia/excessive fluid intake - Yes, No Current Physician Ordered Diet: Independent, Set-up Assistance Required, Requires Prompts, Requires Encouragement, Client must be fed by staff, Tube Feeding, Eating Drinking Meal Requires special utensils, Requires special positioning/unique instructions Describe protocol, concerns and precautions Independent, Requires prompting/reminders, Requires assistance, Requires special cup or Requires special positioning/unique instructions, Tube feeding Describe protocol, concerns and precautions Independently and safely prepares meals requiring cooking Independently and safely prepares basic meals not requiring cooking Requires assistance with meal planning/making healthy choices Requires assistance when cooking Requires assistance to prepare simple meals Totally Dependent on staff for meal preparation Food Likes Food Dislikes Comments: Bladder Bowel Toileting Continent, Occasional Incontinence, Incontinent, Wears Depends, Catheter, Urostomy, Describe protocols, concerns, precautions Continent, Occasional Incontinence, Incontinent, Wears Depends Ileostomy, Colostomy, Describe protocols, concerns, precautions
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