RESIDENT FOOD SURVEY

Resident Name Date

__________________________ __ /__ /__

Please fill in the following spaces with responses from the resident.

What is your favorite meal: What is your least favorite food:

Allergies: What time do you usually eat?

Breakfast Lunch Dinner
___:___ ___:___ ___:___
AM AM/PM PM
Religion: Food Restrictions Due to Religion:

Please have the resident’s doctor respond to the following questions.

Please list the resident’s medications: What dietary restrictions are caused by the
medications?

The next section is to be filled out by the dietary manager.

Meals the resident should like: Meals the resident would not like:

Resident is allergic to the following meals: What time do you usually eat?
Breakfast Lunch Dinner
___:___ ___:___ ___:___
AM AM/PM PM