Primary Care Provider (Pcp) Authorization Form : G-Tube/swallowing/feeding Disorders - Jefferson County Public Schools Health Services

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Jefferson County Public Schools Health Services
Primary Care Provider (PCP) Authorization: G-Tube/Swallowing/Feeding Disorders (Side One)
2012-2013 School Year
Student Name: __________________________Date of Birth: __________________School: __________________________________
***Diagnosis: ____________________________________________
***Latex Allergy:
YES
NO
Type of G-tube
SWALLOWING & FEEDING DISORDERS
Is child allowed to have any food/drink by mouth?
Button
Catheter
Yes
No
Name of formula: __________________________________
Feeding formula must be sent to school in the original unopened
HAS CHILD HAD A SWALLOW TEST IN THE LAST TWO (2) YEARS?
container
Yes
No
IF YES, PLEASE ATTACH COPY OF MOST RECENT SWALLOW
Pump to be used:
Yes
No
TEST.
Type of pump: ______________________
1. Does this student have a disability?
Yes
No,
Flow rate ________cc/hour
If Yes, Describe the major life activities affected by the disability: ___
___________________________________________________________
Gravity:
Yes
No
2. Does this student have special nutritional/feeding needs?
Yes
No
Volume to be given: _________oz
If Yes, Describe: ___________________________
Volume of water to follow feeding: _______ cc
3. List any medical dietary restrictions, special diet, and/or life threatening
food allergies. ____________________________________
Positions:
*** Please note if life threatening food allergies then an Asthma/ Food
During feeding: _____________ After feeding: ________________
Allergies PCP form needs to be completed.***
Feeding time(s): _______
________ ________
_______
NUTRITIONAL SERVICES CANNOT PROVIDE A DIET
MODIFICATION WITHOUT PRIMARY CARE PROVIDER
May additional water be administered for outdoor field trips during warm
DIRECTIONS
weather?
Yes
No
Amount _______________
4. List foods that need textural modification (If all foods need to be prepared
in this manner indicate “ALL”)
If G-tube becomes dislodged can a trained Nurse replace it?
Cut up or chopped into bite size pieces: ______________________________
Yes
No
Finely ground: _________________________________________________
Pureed: _______________________________________________________
Additional Health Care Provider’s Comments: ___________________
Other Specifications: ____________________________________________
5. Feeding/Oral Motor Recommendations: ____________________________
_________________________________________________________________
6. Feeding Equipment: _____________________________________________
_________________________________________________________________
7. Positioning for Feeding/Eating: ____________________________________
Please Complete Both Sides of Form. Form MUST be Signed by
Health Care Provider and Parent/Guardian
Initials/Date
Reviewed by Health Services
___________
Entered by Health Services
___________
School received/sent to Health Services ___________

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