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<pre>
 Rm:<INPUT TYPE='text' NAME='froom' size=6 value='      '>    Name:<INPUT TYPE='text' NAME='fname' size=25 value='                        '>  Resno:<INPUT TYPE='text' NAME='fresno' size=7 value='NL24834'READONLY> Sx:<INPUT TYPE='text' NAME='fgender' size=1 value=' '>  Hgt:<INPUT TYPE='text' NAME='fhgt' size=5 value='66E'>in.  FacNo:<INPUT TYPE='text' NAME='fhnum' size=1 value='1' READONLY><br />
ADt:<INPUT TYPE='text' NAME='fDOA' size=8 value='11-21-24'>    DOB:<INPUT TYPE='text' NAME='fDOB' size=10 value='          '>  NMP:<INPUT TYPE='text' NAME='fnmp' size=6 value='A     '> Sel:<INPUT TYPE='text' NAME='fselmenu' size=1 value=' '> PhyNo:<INPUT TYPE='text' NAME='fphno' size=3 value='   '>  Phy:<INPUT TYPE='text' NAME='fphynm' size=18 value='                  '><br />
  1:<INPUT TYPE='text' NAME='fdno1' size=3 value='   '> D1:<INPUT TYPE='text' NAME='fdnm1' size=13 value='             '> 2:<INPUT TYPE='text' NAME='fdno2' size=3 value='   '> D2:<INPUT TYPE='text' NAME='fdnm2' size=13 value='             '> 3:<INPUT TYPE='text' NAME='fdno3' size=3 value='   '> D3:<INPUT TYPE='text' NAME='fdnm3' size=14 value='              '> 4:<INPUT TYPE='text' NAME='fdno4' size=3 value='   '>  D4:<INPUT TYPE='text' NAME='fdnm4' size=10 value='          '><br />
BLc:<INPUT TYPE='text' NAME='bloc' size=3 value='RM '>        LLc:<INPUT TYPE='text' NAME='lloc' size=3 value='RM '>       SLc:<INPUT TYPE='text' NAME='sloc' size=3 value='RM '><br />

<p style='background-color: #33FF00' /p>  LIKES:<br />L1: <INPUT TYPE='checkbox' NAME='likes1'> <INPUT TYPE='text' NAME='lknm1' color: #33FF00 size=18 value='.Coffee all Meals ' READONLY >  L2: <INPUT TYPE='checkbox' NAME='likes2' > <INPUT TYPE='text' NAME='lknm2' size=18 value='.Nectar Thick Liq.' READONLY>  L3: <INPUT TYPE='checkbox' NAME='likes3' > <INPUT TYPE='text' NAME='lknm3' size=18 value='.Honey Thick Liq. ' READONLY>  L4: <INPUT TYPE='checkbox' NAME='likes4' > <INPUT TYPE='text' NAME='lknm4' size=18 value='.Pudding Thick Lq ' READONLY>  L5: <INPUT TYPE='checkbox' NAME='likes5' > <INPUT TYPE='text' NAME='lknm5' size=18 value='.Large Portions   ' READONLY><br />L6: <INPUT TYPE='checkbox' NAME='likes6'  value='.' > <INPUT TYPE='text' NAME='lknm6' size=18 value='.Double Desserts  ' READONLY>  L7: <INPUT TYPE='checkbox' NAME='likes7'  value='.' > <INPUT TYPE='text' NAME='lknm7' size=18 value='.Double Meat/Eggs ' READONLY>  L8: <INPUT TYPE='checkbox' NAME='likes8'  value='.' > <INPUT TYPE='text' NAME='lknm8' size=18 value='.Extra Margarine  ' READONLY>  L9: <INPUT TYPE='checkbox' NAME='likes9'  value='.' > <INPUT TYPE='text' NAME='lknm9' size=18 value='.Milk All Meals   ' READONLY>  10: <INPUT TYPE='checkbox' NAME='likes10'  value='.' > <INPUT TYPE='text' NAME='lknm10' size=18 value='.Milk+Juice BLS   ' READONLY><br />11: <INPUT TYPE='checkbox' NAME='likes11'  value='.' > <INPUT TYPE='text' NAME='lknm11' size=18 value='Fortified Cereal  '>  12: <INPUT TYPE='checkbox' NAME='likes12'  value='.' > <INPUT TYPE='text' NAME='lknm12' size=18 value='Fortified Eggs    '>  13: <INPUT TYPE='checkbox' NAME='likes13'  value='.' > <INPUT TYPE='text' NAME='lknm13' size=18 value='Fortified Soup    '>  14: <INPUT TYPE='checkbox' NAME='likes14'  value='.' > <INPUT TYPE='text' NAME='lknm14' size=18 value='Fortified Potato  '>  15: <INPUT TYPE='checkbox' NAME='likes15'  value='.' > <INPUT TYPE='text' NAME='lknm15' size=18 value='.Fortified Foods  ' READONLY><br />16: <INPUT TYPE='checkbox' NAME='likes16'  value='.' > <INPUT TYPE='text' NAME='lknm16' color: #33FF00 size=18 value='HShake at Brk     '>  17: <INPUT TYPE='checkbox' NAME='likes17'  value='.' > <INPUT TYPE='text' NAME='lknm17' size=18 value='HShake at Lch     '>  18: <INPUT TYPE='checkbox' NAME='likes18'  value='.' > <INPUT TYPE='text' NAME='lknm18' size=18 value='HShake at Sup     '>  19: <INPUT TYPE='checkbox' NAME='likes19'  value='.' > <INPUT TYPE='text' NAME='lknm19' size=18 value='HiCal Pudding     '>  20: <INPUT TYPE='checkbox' NAME='likes20'  value='.' > <INPUT TYPE='text' NAME='lknm20' size=18 value='Pudding           '><br />21: <INPUT TYPE='checkbox' NAME='likes21'  value='.' > <INPUT TYPE='text' NAME='lknm21' size=18 value='HiCal Pud at Sup  '>  22: <INPUT TYPE='checkbox' NAME='likes22'  value='.' > <INPUT TYPE='text' NAME='lknm22' size=18 value='Cr of Wheat @Brk  '>  23: <INPUT TYPE='checkbox' NAME='likes23'  value='.' > <INPUT TYPE='text' NAME='lknm23' size=18 value='Grits at Brk      '>  24: <INPUT TYPE='checkbox' NAME='likes24'  value='.' > <INPUT TYPE='text' NAME='lknm24' size=18 value='Oatmeal at Brk    '>  25: <INPUT TYPE='checkbox' NAME='likes25'  value='.' > <INPUT TYPE='text' NAME='lknm25' size=18 value='Fried Egg @Brk    '><br />26: <INPUT TYPE='checkbox' NAME='likes26'  value='.' > <INPUT TYPE='text' NAME='lknm26' size=18 value='Poached Egg @Brk  '>  27: <INPUT TYPE='checkbox' NAME='likes27'  value='.' > <INPUT TYPE='text' NAME='lknm27' size=18 value='Coffee All Meals  '>  28: <INPUT TYPE='checkbox' NAME='likes28'  value='.' > <INPUT TYPE='text' NAME='lknm28' size=18 value='Decaf             '>  29: <INPUT TYPE='checkbox' NAME='likes29'  value='.' > <INPUT TYPE='text' NAME='lknm29' size=18 value='Cottage Cheese    '>  30: <INPUT TYPE='checkbox' NAME='likes30'  value='.' > <INPUT TYPE='text' NAME='lknm30' size=18 value='Yogurt            '><br /> <p style='background-color: #FF6699' /p>  DISLIKES:<br />D1: <INPUT TYPE='checkbox' NAME='dlikes1'  value='.' > <INPUT TYPE='text' NAME='dlknm1' size=18 value='.No Milk          ' READONLY>  D2: <INPUT TYPE='checkbox' NAME='dlikes2'  value='.' > <INPUT TYPE='text' NAME='dlknm2' size=18 value='.No Milk Products ' READONLY>  D3: <INPUT TYPE='checkbox' NAME='dlikes3'  value='.' > <INPUT TYPE='text' NAME='dlknm3' size=18 value='.No Pork          ' READONLY>  D4: <INPUT TYPE='checkbox' NAME='dlikes4'  value='.' > <INPUT TYPE='text' NAME='dlknm4' size=18 value='.No Beef          ' READONLY>  D5: <INPUT TYPE='checkbox' NAME='dlikes5'  value='.' > <INPUT TYPE='text' NAME='dlknm5' size=18 value='.No Chicken       ' READONLY><br />D6: <INPUT TYPE='checkbox' NAME='dlikes6'  value='.' > <INPUT TYPE='text' NAME='dlknm6' size=18 value='.No Turkey        ' READONLY>  D7: <INPUT TYPE='checkbox' NAME='dlikes7'  value='.' > <INPUT TYPE='text' NAME='dlknm7' size=18 value='.No Fish          ' READONLY>  D8: <INPUT TYPE='checkbox' NAME='dlikes8'  value='.' > <INPUT TYPE='text' NAME='dlknm8' size=18 value='.No Seafood       ' READONLY>  D9: <INPUT TYPE='checkbox' NAME='dlikes9'  value='.' > <INPUT TYPE='text' NAME='dlknm9' size=18 value='.No Eggs          ' READONLY>  10: <INPUT TYPE='checkbox' NAME='dlikes10'  value='.' > <INPUT TYPE='text' NAME='dlknm10' size=18 value='.No Strawberries  ' READONLY><br />11: <INPUT TYPE='checkbox' NAME='dlikes11'  value='.' > <INPUT TYPE='text' NAME='dlknm11' size=18 value='.No Tomato Prodcts' READONLY>  12: <INPUT TYPE='checkbox' NAME='dlikes12'  value='.' > <INPUT TYPE='text' NAME='dlknm12' size=18 value='.No Raw Vegies    ' READONLY>  13: <INPUT TYPE='checkbox' NAME='dlikes13'  value='.' > <INPUT TYPE='text' NAME='dlknm13' size=18 value='.No Nuts/Seeds    ' READONLY>  14: <INPUT TYPE='checkbox' NAME='dlikes14'  value='.' > <INPUT TYPE='text' NAME='dlknm14' size=18 value='.No Potatoes/Yams ' READONLY>  15: <INPUT TYPE='checkbox' NAME='dlikes15'  value='.' > <INPUT TYPE='text' NAME='dlknm15' size=18 value='.No Dry Beans     ' READONLY><br />16: <INPUT TYPE='checkbox' NAME='dlikes16'  value='.' > <INPUT TYPE='text' NAME='dlknm16' size=18 value='.No Citrus       ' READONLY>  17: <INPUT TYPE='checkbox' NAME='dlikes17'  value='.' > <INPUT TYPE='text' NAME='dlknm17' size=18 value='No Liver         '>  18: <INPUT TYPE='checkbox' NAME='dlikes18'  value='.' > <INPUT TYPE='text' NAME='dlknm18' size=18 value='No Tuna          '>  19: <INPUT TYPE='checkbox' NAME='dlikes19'  value='.' > <INPUT TYPE='text' NAME='dlknm19' size=18 value='No Quiche        '>  20: <INPUT TYPE='checkbox' NAME='dlikes20'  value='.' > <INPUT TYPE='text' NAME='dlknm20' size=18 value='No Bacon         '><br />21: <INPUT TYPE='checkbox' NAME='dlikes21'  value='.' > <INPUT TYPE='text' NAME='dlknm21' size=18 value='No Sausage       '>  22: <INPUT TYPE='checkbox' NAME='dlikes22'  value='.' > <INPUT TYPE='text' NAME='dlknm22' size=18 value='No Squash        '>  23: <INPUT TYPE='checkbox' NAME='dlikes23'  value='.' > <INPUT TYPE='text' NAME='dlknm23' size=18 value='No Greens        '>  24: <INPUT TYPE='checkbox' NAME='dlikes24'  value='.' > <INPUT TYPE='text' NAME='dlknm24' size=18 value='No Broccoli      '>  25: <INPUT TYPE='checkbox' NAME='dlikes25'  value='.' > <INPUT TYPE='text' NAME='dlknm25' size=18 value='NO Spinach       '><br />26: <INPUT TYPE='checkbox' NAME='dlikes26'  value='.' > <INPUT TYPE='text' NAME='dlknm26' size=18 value='No Peas          '>  27: <INPUT TYPE='checkbox' NAME='dlikes27'  value='.' > <INPUT TYPE='text' NAME='dlknm27' size=18 value='No Corn          '>  28: <INPUT TYPE='checkbox' NAME='dlikes28'  value='.' > <INPUT TYPE='text' NAME='dlknm28' size=18 value='No Okra          '>  29: <INPUT TYPE='checkbox' NAME='dlikes29'  value='.' > <INPUT TYPE='text' NAME='dlknm29' size=18 value=' Isolation       ' READONLY>  30: <INPUT TYPE='checkbox' NAME='dlikes30'  value='.' > <INPUT TYPE='text' NAME='dlknm30' size=18 value='.Allergies       ' READONLY><br />

<INPUT type="submit" value="Submit Changes">


<p style="background-color: #FFFF99" /p>
   Breakfast Tolerances                      Lunch Tolerances                            Supper Tolerances
 <INPUT TYPE='text' NAME='bt1' size=32 value='                                '><INPUT TYPE='text' NAME='bd1' size=7 value='       '>  <INPUT TYPE='text' NAME='lt1' size=32 value='                                '><INPUT TYPE='text' NAME='ld1' size=7 value='       '>  <INPUT TYPE='text' NAME='st1' size=32 value='                                '><INPUT TYPE='text' NAME='sd1' size=7 value='       '><br /> <INPUT TYPE='text' NAME='bt2' size=32 value='                                '><INPUT TYPE='text' NAME='bd2' size=7 value='       '>  <INPUT TYPE='text' NAME='lt2' size=32 value='                                '><INPUT TYPE='text' NAME='ld2' size=7 value='       '>  <INPUT TYPE='text' NAME='st2' size=32 value='                                '><INPUT TYPE='text' NAME='sd2' size=7 value='       '><br /> <INPUT TYPE='text' NAME='bt3' size=32 value='                                '><INPUT TYPE='text' NAME='bd3' size=7 value='       '>  <INPUT TYPE='text' NAME='lt3' size=32 value='                                '><INPUT TYPE='text' NAME='ld3' size=7 value='       '>  <INPUT TYPE='text' NAME='st3' size=32 value='                                '><INPUT TYPE='text' NAME='sd3' size=7 value='       '><br /> <INPUT TYPE='text' NAME='bt4' size=32 value='                                '><INPUT TYPE='text' NAME='bd4' size=7 value='       '>  <INPUT TYPE='text' NAME='lt4' size=32 value='                                '><INPUT TYPE='text' NAME='ld4' size=7 value='       '>  <INPUT TYPE='text' NAME='st4' size=32 value='                                '><INPUT TYPE='text' NAME='sd4' size=7 value='       '><br /> <INPUT TYPE='text' NAME='bt5' size=32 value='                                '><INPUT TYPE='text' NAME='bd5' size=7 value='       '>  <INPUT TYPE='text' NAME='lt5' size=32 value='                                '><INPUT TYPE='text' NAME='ld5' size=7 value='       '>  <INPUT TYPE='text' NAME='st5' size=32 value='                                '><INPUT TYPE='text' NAME='sd5' size=7 value='       '><br /> <INPUT TYPE='text' NAME='bt6' size=32 value='                                '><INPUT TYPE='text' NAME='bd6' size=7 value='       '>  <INPUT TYPE='text' NAME='lt6' size=32 value='                                '><INPUT TYPE='text' NAME='ld6' size=7 value='       '>  <INPUT TYPE='text' NAME='st6' size=32 value='                                '><INPUT TYPE='text' NAME='sd6' size=7 value='       '><br />
<p style="background-color: #FF6600" /p>
   10 am Nourishments                      2pm/3pm Nourishments                     HS Nourishments
 <INPUT TYPE='text' NAME='nm1' size=29 value='                             '><INPUT TYPE='text' NAME='nmd1' size=7 value='       '>  <INPUT TYPE='text' NAME='na1' size=29 value='                             '><INPUT TYPE='text' NAME='nad1' size=7 value='       '>  <INPUT TYPE='text' NAME='nhs1' size=29 value='                             '><INPUT TYPE='text' NAME='nhsd1' size=7 value='       '><br /> <INPUT TYPE='text' NAME='nm2' size=29 value='                             '><INPUT TYPE='text' NAME='nmd2' size=7 value='       '>  <INPUT TYPE='text' NAME='na2' size=29 value='                             '><INPUT TYPE='text' NAME='nad2' size=7 value='       '>  <INPUT TYPE='text' NAME='nhs2' size=29 value='                             '><INPUT TYPE='text' NAME='nhsd2' size=7 value='       '><br /> <INPUT TYPE='text' NAME='nm3' size=29 value='                             '><INPUT TYPE='text' NAME='nmd3' size=7 value='       '>  <INPUT TYPE='text' NAME='naft1' size=29 value='                             '><INPUT TYPE='text' NAME='naftd1' size=7 value='       '>  <INPUT TYPE='text' NAME='nhs3' size=29 value='                             '><INPUT TYPE='text' NAME='nhsd3' size=7 value='       '><br /> <INPUT TYPE='text' NAME='nm4' size=29 value='' READONLY><INPUT TYPE='text' NAME='nmd4' size=7 value='' READONLY>  <INPUT TYPE='text' NAME='naft2' size=29 value='                             '><INPUT TYPE='text' NAME='naftd2' size=7 value='       '><br />

<INPUT type="submit" value="Submit Changes">


<p style="background-color: #99CCFF" /p>
  Medications:
 Med1: <INPUT TYPE='text' NAME='mdn1' size=3 value='   '><INPUT TYPE='text' NAME='md1' size=14 value='              '>  Med 7: <INPUT TYPE='text' NAME='mdn7' size=3 value='   '><INPUT TYPE='text' NAME='md7' size=14 value='              '><br /> Med2: <INPUT TYPE='text' NAME='mdn2' size=3 value='   '><INPUT TYPE='text' NAME='md2' size=14 value='              '>  Med 8: <INPUT TYPE='text' NAME='mdn8' size=3 value='   '><INPUT TYPE='text' NAME='md8' size=14 value='              '><br /> Med3: <INPUT TYPE='text' NAME='mdn3' size=3 value='   '><INPUT TYPE='text' NAME='md3' size=14 value='              '>  Med 9: <INPUT TYPE='text' NAME='mdn9' size=3 value='   '><INPUT TYPE='text' NAME='md9' size=14 value='              '><br /> Med4: <INPUT TYPE='text' NAME='mdn4' size=3 value='   '><INPUT TYPE='text' NAME='md4' size=14 value='              '>  Med10: <INPUT TYPE='text' NAME='mdn10' size=3 value='   '><INPUT TYPE='text' NAME='md10' size=14 value='              '><br /> Med5: <INPUT TYPE='text' NAME='mdn5' size=3 value='   '><INPUT TYPE='text' NAME='md5' size=14 value='              '>  Med11: <INPUT TYPE='text' NAME='mdn11' size=3 value='   '><INPUT TYPE='text' NAME='md11' size=14 value='              '><br /> Med6: <INPUT TYPE='text' NAME='mdn6' size=3 value='   '><INPUT TYPE='text' NAME='md6' size=14 value='              '>  Med12: <INPUT TYPE='text' NAME='mdn12' size=3 value='   '><INPUT TYPE='text' NAME='md12' size=14 value='              '>
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<INPUT type="submit" value="Submit Changes">
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<a href="monofont.exe">One Time Font Download to View Tables Below</a>

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<style type="text/css">
     TEXTAREA {
       font-family: "MONO1";
       font-face:MONO1;
       font-size:14}
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  Diagnosis
<TEXTAREA name="Diag" cols="82" rows="8" READONLY >
|No. | ICD-9  |       Diagnosis          |No. | ICD-9  |      Diagnosis        |
|    |        |                          |    |        |                       |
|    |        |                          |    |        |                       |
|    |        |                          |    |        |                       |
|    |        |                          |    |        |                       |
|    |        |                          |    |        |                       |
|    |        |                          |    |        |                       |
|    |        |                          |    |        |                       |
</TEXTAREA>

<br />
  Tubefeeding  BEE and BMI 
<TEXTAREA name="TF" cols="82" rows="18" READONLY >

|10-13-10|5  |NAS          |   |             |   |              |   |          |
|  -  -  |   |             |   |             |   |              |   |          |
|  -  -  |   |             |   |             |   |              |   |          |
|  -  -  |   |             |   |             |   |              |   |          |
|  -  -  |   |             |   |             |   |              |   |          |
|  -  -  |   |             |   |             |   |              |   |          |
|-|REQ|--|--------------CW-----------------------------------------------------|
|Kcal Adj:       |     |  |- Receiving -|- Factors --|---- BEE Calculations ---|
|Calories:1584.3 kcal/day |             |Actvity:1.3 |655+(4.3*130)      | Adj |
|Protein :47.27  g/day    |             |Stress :1   |+(4.7*66)-(4.7*65 )|     |
|Fluid   :1773   cc/day   |             |Protein:.8  |*1.3 *1   |BMI:0   |     |
|------------------------------------------------------------------------------|
|TF:    |                                     %RDA |- Volume Calculations (cc)-|
|Formula|                                          |    | |    | |    |=       |
|Flush  |                                          |    | |    | |    |=       |
|----------------------------------------------  % |----|-|----|-|----|--------|
|  -  -  |Dx:                    |   |Dextrose|    |    | |    | |    |=       |
|------------------------------------|Amino A.|    |    | |    | |    |=       |</TEXTAREA>
<br />
  Weights
<TEXTAREA name="Weights"  cols="82" rows="54" READONLY >
|  Date  |Weight|% chg| Kg  |Sc| w*#< | e+@> |7days|30 days|90 days|180 days|CP|
|  -  -  |   .  |     |     |  |-------------|-----|-------|-------|--------|--|
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|  -  -  |   .  |     |     |  |             |     |       |       |        |  |
</TEXTAREA>
<br />
  Labs
<TEXTAREA name="Labs" cols="82" rows="21" READONLY >

|  Date  | Hb | Hct | Alb | Glu | Bun | Cre | K+ |Chol| Na+ | Cl- |mOsmK|      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
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|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
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|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |
|  -  -  |  . |  .  | .   |   . |  .  | .   | .  |    |     |     |     |      |</TEXTAREA>
<br />
  Skin Assessments
<TEXTAREA name="Skin" cols="82" rows="66" READONLY >

|  Date  |w| Location  |g| L  | W  | D  |Wk|PVECd|OD|TCodes|Acquired| Family |M|
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
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|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
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|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
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|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
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|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |
|  -  -  | |           | |    |    |    |  |     |  |      |  -  -  |  -  -  | |</TEXTAREA>
<br />
  Meal/Snack Consumption and I/O's
<TEXTAREA name="Meals" cols="82" rows="50" READONLY >

|  Date  |B|L|S|11-7|7-3 |3-11|1|3|H|11-7|7-3 |3-11|Total|11-7|7-3 |3-11|Total |
|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |
|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |
|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |
|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |
|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |
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|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |
|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |
|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |
|  -  -  | | | |    |    |    | | | |    |    |    |     |    |    |    |      |
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</p>


  Dietitian Comments
<TEXTAREA name="dCmt" cols="162" rows="50" READONLY Wrap=Off >
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</TEXTAREA>

<br />

  CDM Comments
<TEXTAREA name="cCmt" cols="162" rows="50" READONLY Wrap=Off >
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