Diet Order - Arizona Department Of Education
ADVERTISEMENT
1
2DIET ORDER
Arizona Department of Education
Heath and Nutrition Services
Medical Statement for Student with Special Diet Needs
School Nutrition Programs
____________
_______________________________________________________________________________________________________
Part I (to be filled out by parent or guardian)
Name of Student: (Last) __________________________________ (First)__________________________________ (MI)______
Social Security Number _______ – _______ – _____________
Date of Birth _____/_____/_____
Age _________
School Attended by Student __________________________________________________________________________________
Parent/Guardian’s Daytime Phone Number(s) (
) _______–__________
(
) _______–__________
Name of Parent/Guardian(s)___________________________________________________________________________________
Signature of Parent/Guardian _________________________________________________________________________________
__________________________________________________________________________________________________________
Part II (to be filled out by Physician)
Patient’s Diagnosis _________________________________________________________________________________________
Describe the patient’s condition and the major life activity affected by the condition related to the need for dietary modification:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Indicate which dietary modification the patient needs and specify what changes need to be made:
Texture Modification:
pureed
ground
chopped
other __________________________________________
Specify Foods _____________________________________________________________________
Tube Feeding:
Formula Name _____________________________________________________________________
Administering Instructions ____________________________________________________________
Oral Feeding:
No
Yes
If Yes, Specify Foods _____________________________________
Nutrient Modification:
Increase Calories
Description: ____________________________________________________
______________________________________________________________
______________________________________________________________
Supplement Name: ______________________________________________
Decrease Calories
Description: ____________________________________________________
______________________________________________________________
______________________________________________________________
Nutrient Restriction Description: ____________________________________________________
______________________________________________________________
______________________________________________________________
Special Mealtime Equipment: ______________________________________________________________________________
Other: _________________________________________________________________________________________________
Dietitian’s Name (if available): _________________________________________________ Phone (
) ______–_________
Physician:
Name _____________________________________________________
Phone (
) ______–_________
Address ____________________________________________________________________________________
PHYSICIAN SIGNATURE ____________________________________________________ Date _______________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal