SOUTH CAROLINA SCHOOL FOOD SERVICES
Diet Prescription for Meals at Schools
Purpose: To provide a method of collecting all information required by Federal regulations for students who cannot eat a regular diet.
NAME OF STUDENT: ______
(To be filled out by the doctor):
List diagnosis (disability or medical condition) that requires the student to have a special diet: ______
______
Briefly describe the major life activity affected by the student’s disability:
______
DIET PRESCRIPTION:
· CALORIC REQUIREMENTS: (indicate the total amount of calories needed to each meal. Attach a meal plan, if applicable):
Breakfast Lunch
Diabetic diet ______
Increased calorie diet ______
Reduced calorie diet ______
Other diet (describe): ______
· MODIFIED TEXTURE: (check the allowed texture):
_____ Regular _____ Chopped _____ Ground _____ Pureed
· FOODS OMITTED AND SUBSTITUTIONS: (please list the specific foods to be omitted and suggest substitutions on the back of this form): ®
· OTHER INFORMATION REGARDING DIET OR FEEDING (please attach additional information to this form or use the back of this form): ®
I certify that the above named student needs special school meals prepared as described above because of the student’s disability or chronic medical condition.
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Physician’s Signature Office Phone # Date
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Registered Dietician (if available) Office Phone # Date
Reviewed June 2010
FOODS OMITTED AND SUBSTITUTIONS:
FOODS TO OMIT : SUGGESTED SUBSTITUTIONS:
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ADDITIONAL INFORMATION:
______
Reviewed June 2010