Nutrition Interventions for Children with Special Health Care Needs

Appendix p
diet Order for Meals at School
Student’s name Age Grade
Disability
Major life activity affected
or
Nondisabling medical condition
Diet Order (check all that apply):
Increased calorie #kcal Texture Modification
Decreased calorie #kcal
Chopped
PKU
Ground
Food allergy
Pureed
Other: ___________________
Liquified
Tube feeding
Liquified Meal
Formula type
Foods to Omit Foods to Substitute
Appendix P
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.
Office phone number Date
Physician or recognized medical authority signature (circle)
(Child Nutrition Services 10/97)
Nutrition Interventions for Children With Special Health Care Needs 375