1. Dysphagia Modified Diet
Please delete this text box once read. Complete all sections and save as a new name. There is an alternate page 1 at the end, for people who do not have a dysphagia diet or thickened drinks, delete this page if not needed. Print and laminate to ensure it is durable and easily wiped clean.
Personal Place Mat
Name Date
Please read this important information about my mealtimes that you need to know to help make my mealtimes safe, successful and pleasurable. It will tell you about the type of food I eat, how I choose my food and if I need any help to eat. Many people need some help and support at mealtimes. Having this information on a place mat allows staff to read it when they need to. If people cannot easily speak for themselves a Personal Place Mat can help keep them safe. If you go to a new place to eat or there is a new person helping you they can read your Personal Place Mat.
Please think about people who may need a copy.
Add photograph
Dysphagia Modified Diet
Texture C
Puree
Texture D
Pre-mashed
Texture E
Fork Mashable
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Food is smooth and moist with no lumps.
It does not need to be chewed.
Food is soft, tender, moist and easily chewed. It can be mashed with a fork. It can be easily broken up with a fork.
Food is soft, tender and moist and needs very little chewing.
It has been mashed up before serving.
Pieces of soft tender meat should be no bigger that 1½ cm or ¾ inch.
It sometimes requires a thick sauce, gravy or custard.
It is thick enough to hold its own shape on a plate when scooped.
It cannot be poured.
It usually requires a very thick, smooth (non-pouring) sauce, gravy or custard.
Avoid or modify the following types of food that can cause a high risk of choking for anyone with a swallowing difficulty. Hard, tough, chewy, fibrous, stringy, dry, crispy, crunchy , crumbly, sticky and floopy foods. Juicy food where juice separates off in the mouth to a mixed texture e.g. water melon. And foods of mixed consistency (e.g. soup with lumps of vegetables).
Thickened Drinks
Stage 1
Syrup thick
Stage 2
custard thick
Stage 3
pudding thick
it will look or feel like the consistency of double cream and can be drunk from a cup. It will run easily through a fork.
it will look or feel like the consistency of tinned custard and can be drunk from a cup. It will drip slowly through a fork.
it will look or feel like the consistency of jam/mousse and needs to be taken with a spoon. It will sit on a fork.
If there are any concerns or changes to swallowing withdraw placemat immediately and refer to SLT. Some of the clinical signs that can indicate a swallowing difficulty include coughing/choking on food or drink, wet gargly voice, recurrent chest infections, weight loss. It is the responsibility of care staff to review this placemat Name of person who completed mat:
AC/SLT/BHSCT/Jan2015

2. Personal Place Mat Name: Date: Name of person who completed mat:
Swallow This is placeholder text to replace with your own words.
This section should state if you have ever had a swallowing assessment and date of your last report.
Food. This is placeholder text to replace with your own words.
State if you are on a special diet or dysphagia diet, e.g. C = puree diet, D = pre-mashed, E= fork mashable. Describe how to prepare food. State any allergies. Estimate amount if important. Indicate particular likes and dislikes.
Drink. This is placeholder text to replace with your own words.
State if on thickened drinks, e.g. stage 1 syrup, stage 2 custard, stage 3 pudding. Describe how to give drinks, pace, amount and temperature if important. Describe likes and dislikes.
Routine, where and when This is placeholder text to replace with your own words. Describe important environmental factors including, noise level, position within the room, who you eat with. Describe important eating routines. Estimate frequency and timing of food and drink.
Position This is placeholder text to replace with your own words. Outline special seating or furniture, e.g. chair with arms, wheelchair, small table. Support needed to achieve and maintain an upright posture. It may be useful to include a photograph or refer to a postural passport.
Equipment and protection. This is placeholder text to replace with your own words. List all specialised equipment, e.g. scoop bowl, non-slip mat. It may be useful to insert a photograph. Detail how to protect your clothing from spillage.
Communication This is placeholder text to replace with your own words. Describe how you communicate, e.g. that you are hungry, thirsty, want more, had enough, in pain etc. Describe how you choose what you want to eat and drink, e.g. if you choose from a photographic menu.
Supervision This is placeholder text to replace with your own words. State if you require any support or supervision at mealtimes and what level of supervision.
Risks and help I need. Highlight any risks at mealtimes, e.g. choking, aspiration. Include any medical conditions that could impact on eating and drinking, e.g. epilepsy, diabetes. How you take medications safely. Any oral hygiene routine or how to support you to freshen up after eating.
If there are any concerns or changes to swallowing withdraw placemat immediately and refer to SLT. Some of the clinical signs that can indicate a swallowing difficulty include coughing/choking on food or drink, wet gargly voice, recurrent chest infections, weight loss. It is the responsibility of care staff to review this placemat.
AC/SLT/BHSCT/Jan2015

3. Personal Place Mat Name Date Add photograph
Please delete this text box, once read. This is an alternative page 1 for anyone who does not require a dysphagia diet or thickened liquids. Delete this page if not needed.
Personal Place Mat
Name Date
Please read this important information about my mealtimes that you need to know to help make my mealtimes safe, successful and pleasurable.
It will tell you about the type of food I eat, how I choose my food and if I need any help to eat.
Many people need some help and support at mealtimes.
Having this information on a place mat allows staff to read it
when they need to. If people cannot easily speak for themselves a Personal Place Mat can help keep them safe.
If you go to a new place to eat or there is a new person
helping you they can read your Personal Place Mat.
Please think about people who may need a copy.
Add photograph
If there are any concerns or changes to swallowing withdraw placemat immediately and refer to SLT. Some of the clinical signs that can indicate a swallowing difficulty include coughing/choking on food or drink, wet gargly voice, recurrent chest infections, weight loss. It is the responsibility of care staff to review this placemat Name of person who completed mat:
AC/SLT/BHSCT/Jan2015