Highline School District

Diet Prescription for Meals at School

Student Name ______D.O.B.: ______School: ______

Disability: ______

Major Life Activity Affected: ______OR

Non disabling Medical Condition: ______

Physician Request: (Check all that apply)

Increased Calorie ______#kcal Decreased Calorie ______#kcal Diabetic

PKU Texture Modification (*see below) Food Allergy

If food are listed to be omitted from diet-foods to substitute must be listed.

Foods to Omit: Foods to Substitute:

______

______

Has swallow study been completed for this student? ______Date ______Yes ______No

Is a swallow study recommended at this time? ______Yes ______No

Is this student considered safe at school for oral nutrition and/or Hydration? ______Yes ______No

If so, at what level? (These are the only options provided by Highline Schools Nutrition Services).

Food Texture: (select only one) / Liquid Consistency: (select only one)
_____ NPO _____ Mechanical soft
_____ G- Tube _____ Pureed
_____ Regular / _____ Honey Thick
_____ Nectar Thick
_____ Thin
Feeding Procedures (i.e. alternate bites/sips, alternate liquids/solids, max. time, pace, small bites, etc.) / Equipment: / Positioning:

Gastrostomy Tube Feeding Please clarify if it is: Bolus, gravity or pump.

Formula / Time / Amount and flow rate: / Amount of Water Flush
Physician Authorization
I request and authorize that the above named student be provided the above identified treatment in accordance with the instructions indicated above for the period starting with the ______day of ______, 20______through the ______day of ______20_____ as there exists a valid health reason which makes treatment advisable during the school hours or during such time that the student is under the supervision of school officials.
______
Health Care Provider signature Date signed
Name: ______Office Phone: ______Fax: ______
Type or Print

Parent Request

I certify that I am the parent, legal guardian, or other person in legal control of the above identified student and request and authorize the school to provide treatment to the above student in accordance with the prescription or doctor’s instructions written below. I also give my permission for exchange of information between the school district staff and the health care provider regarding this treatment request.

Signature: ______Date: ______

Telephone Number: ______

Home Work

Rev 2-10