Dietary Adjustment Rehabilitation Assessment Form
Assess dietary adjustment needs during rehabilitation using the Dietary Adjustment Rehabilitation Assessment Form.
Patient and Rehabilitation Context
Age Range
*
Under 18
18–24
25–34
35–44
45–54
55–64
65+
Prefer not to say
Current Rehabilitation Stage
*
Initial recovery
Active rehabilitation
Maintenance/ongoing support
Preparing for discharge
Other
Primary Diet-Related Rehabilitation Goal
*
Clinician or Program Guidance Being Followed
Dietary Habits and Tolerance Assessment
Current dietary tolerance and meal experience
*
Rows
Never
Sometimes
Often
Always
Low meal frequency
1
2
3
4
Reduced appetite
5
6
7
8
Inconsistent hydration
9
10
11
12
Difficulty tolerating common foods
13
14
15
16
Difficulty chewing
17
18
19
20
Difficulty swallowing
21
22
23
24
Nausea during meals
25
26
27
28
Fatigue during meals
29
30
31
32
Appetite and tolerance level by meal component
Rows
Low
Moderate
High
Breakfast intake
33
34
35
Lunch intake
36
37
38
Dinner intake
39
40
41
Snacks between meals
42
43
44
Overall appetite
45
46
47
Tolerance to solid foods
48
49
50
Tolerance to soft foods
51
52
53
Tolerance to liquids
54
55
56
Typical daily meal frequency
*
1 meal
2 meals
3 meals
4+ meals
Varies day to day
Hydration consistency
*
Low
Moderate
High
Varies day to day
Adjustment Needs and Follow-up
Dietary adjustment priorities
*
Increase calories
Increase protein intake
Adjust texture or consistency
Manage appetite
Reduce nausea or digestive discomfort
Balance blood sugar
Improve hydration
Other
Preferred follow-up support format
*
In-person visit
Phone call
Video call
Written care plan
Other
Additional notes or concerns about meal planning
Submit
Should be Empty: