FOOD PREFERENCES DIET SUPPLEMENTS/SNACKS MAJOR FOOD GROUP PREFERENCE FOOD ALLERGY & INTOLERANCE(S) Vegetarian No Meat Dislikes Fish Dislikes Milk Religious/Cultural Diet Restrictions: Adaptive Equipment Needed: Chewing/Swallowing Difficulties: BEVERAGE PREFERENCE Breakfast Juice: _______________ Coffee Decaf Coffee Water Cream Cream Milk: Yes No Sugar Sugar Lunch Water Coffee Decaf Coffee Milk: Yes No Cream Cream _______________ Sugar Sugar Dinner Water Coffee Coffee Milk: Yes No Cream Cream Other: _______________ Sugar Sugar DIET PREFERENCES NAME: PHYS: RM: MR#:
FOOD PREFERENCES DIET SUPPLEMENTS/SNACKS FOOD ALLERGY & INTOLERANCE(S) MAJOR FOOD GROUP PREFERENCE Vegetarian No Meat Dislikes Fish Dislikes Milk Religious/Cultural Diet Restrictions: Adaptive Equipment Needed: Chewing/Swallowing Difficulties: BEVERAGE PREFERENCE Breakfast Juice: _______________ Water Milk: Yes No Coffee Cream Sugar Decaf Coffee Cream Sugar Lunch Water Milk: Yes No _______________ Coffee Cream Sugar Decaf Coffee Cream Sugar Dinner Water Milk: Yes No Other: _______________ Coffee Cream Sugar Coffee Cream Sugar DIET PREFERENCES NAME: PHYS: RM: MR#:
Brief-Food-Preference-Form.docx