Special Meals Prescription Form printable pdf download

Special Meals Prescription Form

SPECIAL MEALS PRESCRIPTION FORM

Local School District/Name of Institution:

Street Address:

City:

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

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

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

Special Meals Prescription Form

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