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Special Diet Statement
Special Diet Statement
Participant Information
Required Information : Dietary Accommodation
List the food to be avoided:
Briefly explain how exposure to this food affects the participant:
List foods to be omitted and substituted. Attach a sheet with additional instructions as needed.
Foods to be Omitted
Foods to be Substituted
Additional information
Texture Modification:
Pureed
Ground
Bite-Sized Pieces
Other
Tube Feeding:
Administering Instructions:
Oral Feeding?
Yes
No
Other Dietary Modification or Additional Instructions(Describe):
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Lakeview CDC
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