Renal Diet Specification Form
Patient Name
Patient ID
Age
Room/Ward
Diet Order
Type of Renal Diet
Pre-dialysis
Hemodialysis
CAPD/Peritoneal
Post-transplant
Texture Modification
Regular
Soft
Pureed
Liquid
Caloric Requirement (kcal)
Protein Requirement (g)
Sodium Restriction (mg)
Potasium Restriction (mg)
Phosphorus Restriction (mg)
Fluid Restriction (ml)
Other Restriction
Additional Instructions
Prescribing Doctor
Date