"Special Meals Prescription Form"

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SPECIAL MEALS PRESCRIPTION FORM
Local School District/Name of Institution:
Street Address:
City:
NH
Zip Code:
Student Name:
DOB:_________________
SASID:
School Name/Institution: (if different than above)
Disability:
Disabled (Federal Policy: as determined by physician)
Non-disabled (school district policy)
Disability or medical condition:
Food Allergy
Food Intolerance
Celiac Disease
Tube Feeding
Diabetes
Cerebral Palsy
Cystic Fibrosis
Spina Bifida
Autism/PDD
Failure to Thrive
Down Syndrome
PKU
Galactosemia
None
Other (specify):
Description of Condition Requiring Special Diet:
Special Diet:
Diabetic
Reduced Calorie
Increased Calorie
Modified Texture
(Check all that apply)
Date Effective: From:
To:
MEATS/PROTEIN FOODS
Can't Have:
Chicken
Pork
Canned/Dried Beans
Nuts/Seeds
Beef
Poultry
Peanut Butter
Soy (Tofu, Soy Protein
Fish
Eggs
No Restriction
Any Meat/Protein Foods
Other (specify):
Food Prep:
Pureed
Ground
Thin Strips ¼"
Bite Size, ¼" by ½"
None
Apply this preparation to all Meat/Protein Foods:
Yes
No
VEGETABLES/FRUIT
Can't Have:
Fruits, fresh
Any fruits/vegetables
Canned
Vegetables, hard/uncooked
Canned with liquids
Other (specify):
Food Prep:
Pureed
Ground
Thin Strips ¼"
Bite Size, ¼" by ½"
None
Drain before puree
Apply this preparation to all Vegetables/Fruit:
Yes
No
GRAINS/BREADS/CEREALS
Can't Have:
Bread/Rolls
Crackers
Taco Shells, hard
Gluten (barley, rye, wheat)
Rice
Tortillas, soft
Pancakes/Waffles
Pasta
French Toast
Cereal
No Restriction
Any Bread/Grains/Cereal Foods
Other (specify):
Food Prep:
Pureed
Thin Strips ¼"
Moistened
None
Ground
Bite Size, ¼" by ½"
Toasted/grilled
Apply this preparation to all Grains/Breads/Cereals:
Yes
No
SPECIAL MEALS PRESCRIPTION FORM
Local School District/Name of Institution:
Street Address:
City:
NH
Zip Code:
Student Name:
DOB:_________________
SASID:
School Name/Institution: (if different than above)
Disability:
Disabled (Federal Policy: as determined by physician)
Non-disabled (school district policy)
Disability or medical condition:
Food Allergy
Food Intolerance
Celiac Disease
Tube Feeding
Diabetes
Cerebral Palsy
Cystic Fibrosis
Spina Bifida
Autism/PDD
Failure to Thrive
Down Syndrome
PKU
Galactosemia
None
Other (specify):
Description of Condition Requiring Special Diet:
Special Diet:
Diabetic
Reduced Calorie
Increased Calorie
Modified Texture
(Check all that apply)
Date Effective: From:
To:
MEATS/PROTEIN FOODS
Can't Have:
Chicken
Pork
Canned/Dried Beans
Nuts/Seeds
Beef
Poultry
Peanut Butter
Soy (Tofu, Soy Protein
Fish
Eggs
No Restriction
Any Meat/Protein Foods
Other (specify):
Food Prep:
Pureed
Ground
Thin Strips ¼"
Bite Size, ¼" by ½"
None
Apply this preparation to all Meat/Protein Foods:
Yes
No
VEGETABLES/FRUIT
Can't Have:
Fruits, fresh
Any fruits/vegetables
Canned
Vegetables, hard/uncooked
Canned with liquids
Other (specify):
Food Prep:
Pureed
Ground
Thin Strips ¼"
Bite Size, ¼" by ½"
None
Drain before puree
Apply this preparation to all Vegetables/Fruit:
Yes
No
GRAINS/BREADS/CEREALS
Can't Have:
Bread/Rolls
Crackers
Taco Shells, hard
Gluten (barley, rye, wheat)
Rice
Tortillas, soft
Pancakes/Waffles
Pasta
French Toast
Cereal
No Restriction
Any Bread/Grains/Cereal Foods
Other (specify):
Food Prep:
Pureed
Thin Strips ¼"
Moistened
None
Ground
Bite Size, ¼" by ½"
Toasted/grilled
Apply this preparation to all Grains/Breads/Cereals:
Yes
No
MILK/DAIRY
Can't Have:
Cheese
Milk
Soy Milk
Ice Cream
Cheese, soft
Lowfat Milk
Yogurt
Yogurt, Frozen
Cheese, hard
Whole Milk
No Restriction
Any Milk/Dairy Foods
Other (specify):
Food Prep:
Pureed
Thin Strips ¼"
Bite Size, ¼" by ½"
Ground
None
Apply this preparation to all Milk/Dairy:
Yes
No
FATS/SAUCES
Can't Have:
No Restrictions
Condiments
Dressings
Low fat Dressings
Gluten
Sauces
High fat Dressings
Any Fats/Sauces
Other (specify):
Spreads
COMBINATION FOODS
Can't Have:
Gluten
Lasagna
Pasta with Sauce
Shepherds Pie
Soup
Any Combination Food
Stews
Pizza
Other (specify):
Food Prep:
Pureed
Thin Strips ¼"
Bite Size, ¼" by ½"
Moistened w/sauce or gravy
Ground
None
Apply this preparation to all Combination Foods:
Yes
No
LIQUIDS
Tube Feeding:
Yes
No
If Yes, specify formula:
Liquids by Mouth Allowed:
Yes
No
Select Type of
Thickeners Needed:
Thickened Syrup
Thickened Nectar*
Thickened Honey*
None
Select Thickeners:
Dry instant baby cereal
Dry instant mashed potato
Dry instant pudding
Fruit pureed/Stage I/II baby
Simply Thick
Thick It
Yogurt
Any Thickener listed
*Nectar= thicken enough to coat a spoon, Honey = thicken enough to stand a straw straight in a cup
Thickening Directions:
SAFE EATING PLAN
(To be completed by Special Education Team or 504 Coordinator)
Describe any special positioning
needed while eating/drinking:
Provide safe eating environment by:
Peanut Free Table
Describe any special utensils or
Quiet Table/Area
feeding equipment needed:
Other:
Describe any special methods for
presenting food/drink:
Liquids served, check all that apply:
bottle
sippy cup
spoon
with straw
juice box holder
other:
PHYSICIAN/MEDICAL AUTHORITY SIGNATURE SECTION
I certify that the above named student needs special meals prepared as described above because
of the student's disability.
I certify that the above named student would benefit from special meals as described above, however this
child is not disabled. It is up to the discretion of each school/institution if and for what conditions they will
provide substitutions.
Physician's/Medical Authority's Signature
Office Phone Number
Date
_________________________________
Physician's/Medical Authority's Printed Name
PARENT/GUARDIAN SECTION
YES Parent/Guardian accepts accommodations offered and his/her child will be participating in the Child
Nutrition Program or any other program offered within the child's institution.
Snack
Breakfast
Lunch
Dinner
NO
Parent/Guardian declines accommodations offered and his/her child will not be participating in the
Child Nutrition Program or any other program offered within the child's institition.
__________________________________________
Parent's/Guardian's Signature
Date
cc:
Parent/Guardian
Physician
Nutritionist
Feeding and Swallowing Specialist
Food Service Director
School Nurse
School Principal
Special Ed Coordinator
For Official Use: Date returned to the Special Ed coordinator at the District Office:
Date
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