Nutritional questionnaire for adults

Dear clients, we are very pleased that you have chosen our facility for your treatment stay. If you have any dietary restrictions or food allergies, please fill out the form below so that we can prepare an appropriate and suitable diet for your stay. If you do not report these restrictions, it will not be possible to provide a diet in the first days of your stay. We would like to inform you that in the event of significant dietary restrictions, we are entitled to not accept you for your stay and invite you on an alternative date.

Name

Last name

Birthdate

Residence ID

Phone

Your preferences:

YES, I have food allergies or intolerances

YES, I prepare my food mechanically (grinding, mixing)

YES, I follow a therapeutic diet (sparing, diabetic, low-salt, weight-loss, etc.)

YES, I use artificial nutrition (milk, sipping, enteral nutrition)

YES, I have individual dietary requirements (only autism spectrum disorder in children)

If at least one of your answers is YES, please contact the nutritional therapists at the e-mail: dietkavesna@janskelazne.com. For children under 2 years of age, it is always necessary to contact the nutritional therapists.