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Appendices<br />

4. Food<br />

List Any Food Likes/Dislikes<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

List Any Dietary Illness/Requirements<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

List Any Difficulties With Eating/Drinking<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

Agreed Short-Term Goals<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

Agreed Long-Term Goals<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

Additional Comments<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

Review Comments<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

___________________________________________________________________________________<br />

Signature: _____________________________ Date:______________<br />

Review Signature: _______________________Date:_______________<br />

Review Signature: _______________________Date:_______________<br />

Review Signature: _______________________Date:_______________<br />

Review Signature: ______________________Date:_______________<br />

392

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