Form A: For Eating Mouths
Form has two parts. Part 1 covers allergens, and Part 2 covers dietary needs beyond allergens. Because the form is long and designed to include many different situations, Part 2 is divided into sections. Please move through the form and complete the sections that are relevant to you.
Full Name
*
First Name
Last Name
Part 1: Allergens (EU / Finland regulations)
Below, pleas choose what applies.
Please select your intolerances. In this context, intolerance means the ingredient itself should be avoided, while cross-contact is usually not critical.
Gluten cereals (wheat, rye, barley,oats, hybrids)
Crustaceans
Egg
Fish
Peanut
Soy
Milk
Treenuts (almond, hazelnut, walnut,cashew, pecan, Brazil nut, pistachio, macadamia)
Celery
Mustard
Sesame
Sulphites (sulphur dioxide andsulphites above threshold)
Lupin
Molluscs
Please select the ingredients that require strict control. In this context, strict control means cross-contact is also a risk, so separate handling is needed.
Gluten cereals (wheat, rye, barley,oats, hybrids)
Crustaceans
Egg
Fish
Peanut
Soy
Milk
Treenuts (almond, hazelnut, walnut,cashew, pecan, Brazil nut, pistachio, macadamia)
Celery
Mustard
Sesame
Sulphites (sulphur dioxide andsulphites above threshold)
Lupin
Molluscs
Part 2: Dietary Needs Beyond Allergies
Choose what applies. For each selection, if there is more to evaluate please leave a note at the end.
2.1 Food philosophies / practices
Vegan
Vegetarian (lacto-ovo)
Lacto-vegetarian
Ovo-vegetarian
Pescatarian
Mostly plant-based
Raw food
Halal
Kosher
No pork
No alcohol
No alcohol (including in cooking)
Fasting-friendly (please give details in the notes part)
2.2 Clinical Nutrition Situations
2.2.1 Diabetes-aware
1. Do you want carbs per portion labelled?
yes
no
2. Carb target range per meal e.g. 15–30 / 30– 45 / 45–60 /, please specify
3. Any fast-acting sugar needed on-site?
yes
no
4. Timing constraint: max gap between eating opportunities (2/3/4/5/6 hours) please specify:
2.2.2 Renal-friendly
1.Do you have specific restrictions?
Low potassium
Low phosphorus
Fluid restriction
Protein limit
Low sodium
2.Your ‘hard no’ foods
3.Do you need nutrition values?
Sodium
Protein
Potassium
2.2.3 Cardiac-friendly
1.Low-salt needed?
Very low
Moderate
No
2.Fat preference:
Low saturated fat
Low fat overall
Not required
3.Any fluid restriction?
Yes
No
4.Caffeine/alcohol avoidance?
Yes
No
5.Nutrition labels needed?
Sodium
Kcal
2.2.4 Low-purine
1.Avoid completely list
Organ meats
Red meat
Alcohol
Yeast extracts
Shellfish
Anchovies/sardines
2.Limit amount list:
Organ meats
Red meat
Alcohol
Yeast extracts
Shellfish
Anchovies/sardines
3.Is seafood okay?
Yes
No
Limited
2.2.5 Post-op / clinical soft diet
1.Texture level needed
soft
minced & moist
pureed
2.Avoid list:
Seeds/Nuts
Raw Veg
Crusty foods
3.Portion size preference:
small
normal
4.Temperature sensitivity
Warm only
Hot is ok
Cold is ok
2.2.6 Histamine intolerance / low-histamine
1.Strictness:
Avoid completely
Small amounts ok
Specific triggers only
2.Top triggers, please list top 5
3.Fermented/aged foods:
Avoid completely
Small amounts ok
Specific triggers only
4.Leftovers/reheating:
Avoid completely
Small amounts ok
Specific triggers only
5.Citrus/tomato triggers?
Avoid completely
Small amounts ok
2.2.7 Insulin resistance
1. Primary aim (choose):
Lower carbs
Higher Fiber
Balanced protein
Nodded Sugar
2. Sweeteners:
Okay
Avoid
3. Carb preference:
Type option 1
Type option 2
Type option 3
Type option 4
2.2.8 Hypoglycaemia
1. Do you need a ‘backup snack’ portion 2. Timing constraint: longest comfortable gap included?
Yes
No
2. Timing constraint: longest comfortable gap included? (hours)
2.2.9 Low-oxalate
1.Avoid completely List:
Spinach
Beetroot
Nuts
Chocolate ☐
Soy
Black tea
Other
2. Limit amount list:
Spinach
Beetroot
Nuts
Chocolate ☐
Soy
Black tea
Other
2.2.10 Meal timing
1. Do you need to eat on a schedule? If yes please specify typical max gap between meals/snacks
2.2.11 Gluten free
1. Need Type:
Celiac-safe (strict cross-contact control)
Gluten-free (non-celiac)
2. Oats:
Only certified gluten-free oats
Avoid oats
Oats ok
3. Also avoid:
Barley/malt
“May contain” warnings
Wheat starch (even if GF)
2.2.12 Low-FODMAP
1. Strictness:
Strict elimination
Moderate / portion-aware
Specific triggers only
2. Avoid list:
Onion
(all forms)
Wheat
Garlic
(all forms)
Rye
Legumes (beans/chickpeas/lentils)
Mushrooms
Cauliflower
Apple
Pear
Mango
Watermelon
Honey
3. Dairy / lactose:
Avoid lactose
Lactose ok
4. Notes (portion limits / tolerated exceptions):
2.2.13 IBS-friendly
1. Avoid list:
High-fat dishes
Very spicy
Carbonated drinks
Onion
Legumes
Dairy
Raw salads
Chili
Caffeine
Garlic
2. Portion style:
small
normal
2.2.14 GERD / reflux-friendly
Type a question
Tomato
Tomato sauce
Citrus
Vinegar
Very acidic sauces
Carbonated drinks
Very fatty foods
Chocolate
Spicy
Fried
Cocoa
Chili
Garlic
Mint
Caffeine
Onion
2. Temperature sensitivity:
Warm only
Cold is ok
Hot is ok
3. Portion style:
Small
Normal
2.2.15 Low-fiber
1. Avoid list:
Whole grains/bran
Nuts/seeds
Raw vegetables
Dried fruit
High-fiber add-ins (chia/flax)
Legumes
Popcorn
Fruit skins
2.2.16 High-fiber
High Fiber
Yes
No
2.3. Metabolic and Nutrition Targets
Targets:
Carb-counted / carb-labeled
Low-carb
Low-carb, high-fiber
Keto
No added sugar
High-protein
Low-protein
Low-fat
High-calorie
Low-histamine
Snack in between big meals
2.4. Texture and Swallowing Access
Texture & Swallowing Access
Soft / easy to chew
Minced & moist
Pureed
Thickened liquids
2.5. Ingredient Exclusion (common)
Ingredient exclusions (common)
No onion
No garlic
No spicy
No mushrooms
No legumes
No seafood (fish + shellfish)
No red meat
No beef
No poultry
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