PDF Louisiana Department of Education School Food Service Section
LOUISIANA DEPARTMENT OF EDUCATION SCHOOL FOOD SERVICE SECTION
DIET PRESCRIPTION FOR MEALS AT SCHOOL **Special Diets will not be supplied and certain foods will not be substituted or omitted,
until this form is filled out by an MD and approved by Child Nutrition Department.**
DIET PRESCRIPTION for MEALS at SCHOOL
Student's Name
School
Parent's Name
Address Street or P. O. Box
City
State
Does the student have a disability that requires a special diet? If Yes, describe the major life activities affected by the disability on back.
Age Grade/Classroom
Telephone Yes________ No_________
If the student is not disabled, list the medical condition that requires special nutritional or feeding needs.
Diet Prescription (Check all that apply.):
____ Diabetic
____ Increased Calorie __________#kcal
____ Food Allergy
____ Reduced Calorie ___________#kcal
____ Hypoglycemic ____ PKU
____ Texture Modification Chopped____ Ground_______ Pureed______ Liquefied______
____ Other_______________
____ Tube Feeding
Liquefied Meal
Formula_____
Foods Omitted and Substitutions (Please check food groups to be omitted. Identify specific foods to omit and list foods to be substituted. If necessary, attach additional information or instructions regarding the diet or feeding.)
Food Groups to Omit ____ Bread and Cereal Products
____ Meat and Meat Alternatives ____ Fruits and Vegetables
____ Milk and Milk Products
Specific Foods to Omit
Specific Foods to Substitute
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.
MUST BE SIGNED BY A DOCTOR
Office Telephone # ( )_________________________
Date: _____________________________
________________________________________________
Licensed Physician/Recognized Medical Authority PRINT
_____________________________________________________ Licensed Physician/Recognized Medical Authority SIGNATURE Revised 4/2016
................
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