Food & Nutrition Services 2014-2015 SPECIAL DIET REQUEST FORM
------For Office Use Only ------
Date Received:______Diet Order: ______School: ______PCS Flagged:____
Notification: SSVCS______Parent______Mgr_____ Nurse______
New Special Diet Request / Change Current Special
Diet Request / RenewExisting Special Diet Request / Temporary Special Diet Request (Start______& End Date______)
Student’s First Name: / Student’s Last Name:
Student’s School & Grade: / Student I.D.#:
Date of Request: / Student Date of Birth:
Completed by Parent & Medical Authority for Student:
I understand it is my responsibility to renew this form before each school year and anytime my child’s medical needs change and also
givepermission for Lyford ISD to contact the Physician’s Office regarding my child’s dietary needs.
My child has a food allergy or special diet but will NOT be consuming food from the Lyford CISD Food & Nutrition Services for
the 2012/13school year. If this changes please contact the Food & Nutrition Services Office at (956)347-3907.
______
Parent/Guardian Signature Parent’s Telephone Number Date
______/ ______/ ______Prescribing Physician/Medical Authority Name / Signature / Phone Number
Medical Authority Credential: / MD / DO / PA / NP
Directions: Complete: Part 1/Section A & B - If the student has a Disability.
Part 2 - If the student has a Non-Life Threatening Food AllergyorFood Intolerance.
PART 1/SECTION A: DISABILITY & FOOD ANAPHYLAXIS (Life Threatening Food Allergy)- To Be Completed By
MedicalAuthorityfor Student
The following information is REQUIRED to make a diet change.
Clinic Contact Person & Phone Number:Circle all disabilities requiring meal modification:
Autism Muscular Dystrophy Heart Disease Hemophilia Asthma Cerebral PalsyMultiple Sclerosis
Rheumatic FeverSickle Cell Anemia Epilepsy Cancer/Leukemia Tuberculosis NephritisLead Poisoning
DiabetesFood Anaphylaxis HIV Metabolic Disorder, Specify______
IMPAIRMENT:Speech Visual Hearing Orthopedic
Traumatic Brain InjuryMental Retardation Emotional DisturbanceDrug Addiction/Alcoholism
Please explain how the disability restricts the student’s diet:
______
Major life activity affected by the DISABILITY (check all that applies):
(NOTE: Lyford CISD cannot honor this document unless at least one life activity is marked.)
EatingHearing / Caring for One’s Self
Speaking / Performing Manual Tasks
Breathing / Walking
Learning / Seeing
Other, specify: ______
Foods to Omit (Ex: omit peanuts, peanut butter, anything w/peanut oil, etc.)______
______
Foods to Substitute (Ex: substitute cheese for peanut butter, etc.)______
______
PART 1/SECTION B: - To Be Completed By Medical Authority for Student
Diet Order(Indicate specific restrictions in space provided)Diabetic Breakfast CHO _____ g/ Lunch CHO ______g/ Snack CHO ______g
Renal K_____g NA _____ g/ Phos _____mg
Sodium Restriction Na _____g
PKU Protein _____g / Cardiac Fat _____g/ NA _____ g
Weight Maintenance Fat _____g/ Kcal ____
Fat Restriction Fat _____g
Other List: ______
Texture Modifications Required (If applicable, specify below.)
Liquids / No RestrictionsThin
Thickened (Nectar)
Thickened (Honey)
Thickened (Pudding / Solids / No Restrictions
Mechanical Soft Chopped
Mechanical Soft Ground
Pureed
Provide additional comments or information as related to diet and/ or feeding techniques: ______
______
LifeThreateningFood Allergies(Food Anaphylaxis)Can the student consume foods where the allergen is an ingredient in the food product? …………………….
(Example: scramble eggs are omitted but egg as an ingredient in
pancakes is allowed)
Explain:______
______
______
______/ NO / YES / Food Allergies
Cheese
Corn
Eggs
Other List: ______
______
______
______/ Soy
Wheat
Milk
Peanuts
PART 2: NON-LIFE THREATENING FOOD ALLERGY OR FOOD INTOLERANCE
Clinic Contact Person & Phone Number:Can the student consume foods where the allergen is an ingredient in the food product? …………………….
(Example: scramble eggs are omitted but egg as an ingredient in pancakes is allowed)
Explain: ______
______/ NO / YES / Food Allergies
Cheese
Corn
Eggs
Other List: ______
______
______/ Soy
Wheat
Milk
Peanuts
Mail or Fax To:LYFORD CISD Food & Nutrition Services
P.O.Drawer 220
LYFORD,TEXAS 78596
(956)347-3907
FAX-(956)347-2937
In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color,national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW,
Washington,D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA
through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.
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