Special Diet & Medication Form
Temporary (End Date: )
Student ID Number:
Male / Female
Date of Birth:
Per the United States Department of Agriculture, a person with a disability is any such person who has an impairment that substantially limits one or more life activities. By definition, this includes but is not limited to diabetes, PKU, celiac disease, food anaphylaxis, learning disabilities, and etc.
THIS SECTION MUST BE COMPLETED BY A LICENSED PHYSICIAN ONLY.
What is the student’s diet restriction?
Is the diet restriction considered a disability? YES / NO (DR. INITIAL ONLY)
If yes, please describe major life activities affected in relation to dietary modification:
Texture Modification: Ground / Chopped / Pureed / Other (please be specific):
Tube Feeding: Formula Name: _____________________ Instructions: ____________________ Oral? _____YES _____NO
Nutrient Modification: Increase Calories __________ Decrease Calories __________ Nutrient Restriction ____________
Omit Foods: ________________________________________ Substitute with: ____________________________________
Does patient have a life threatening food allergy? YES / NO (DR. INITIAL ONLY)
Food Allergies (check all that apply):
All Dairy Products
All Products With Eggs
All Corn Additives
All Foods Produced in Facility With Nut Products
Can patient consume allergen as an ingredient in food product? YES / NO (DR. INITIAL ONLY)
Administration of Medication at School For Treatment of Allergic Reactions
Dosage & Route:
Self Carry (DR. INITIAL ONLY):
Any change of treatment must be requested in writing on this form. Once form is submitted, please allow up to five days for processing. Send completed form to food service department.
By signing below, I understand that it is my responsibility to renew this form any time my child’s medical or health needs change.