Resident Dining Preference and Food Allergy Profile

Resident-level profile for capturing dining likes, dislikes, allergies, dietary restrictions, texture needs, and meal support preferences to help staff provide safer, more personalized meals.

Resident Identification

• Resident full name
• Resident ID or MRN
  Optional if your facility uses a resident identifier. Do not collect if not needed.
• Date completed
• Completed by
  Name and role of the person completing this form, if applicable.

Consent and Information Use

• I understand this information will be used by care, nursing, and dietary staff to support meal planning and food safety.
• Consent to share profile with dietary and kitchen staff
• Preferred contact method for follow-up questions

Dining Preferences

• Favorite foods
• Foods to avoid
• Meal time preferences
• Additional dining notes
  Use this field for brief, relevant details only.

Allergy and Sensitivity Details

• Does the resident have any food allergies or sensitivities?
• Allergy or sensitivity details
• Severity level
• Epinephrine or emergency response plan on file

Diet Texture and Nutrition Support

• Current diet type
• Texture modification
• Fluid consistency
• Nutrition support notes
  Include only information needed for safe meal service and care coordination.

Mealtime Assistance and Cultural Preferences

• Does the resident need mealtime assistance?
• Assistance details
• Cultural or religious food preferences
• Special instructions for staff
  Use for brief, actionable instructions only.