Medical Statement for
Medical Statement for
Non-Disabled Students with Medical or Other Special Dietary Needs
Requiring Special Foods in Child Nutrition Programs
Part I To be competed by School District or Parent/Guardian
Date: _________________________________________________________________
Name of Student: _______________________________________________________
School District: _________________________________________________________
School Name: __________________________________________________________
Part II To be completed by one of the following medical authorities: Licensed Physicians (MD), Physician’s Assistants (PA), Registered Dietitians (RD), Nurse Practitioners (NP), Registered Nurses (RN), Naturopathic Physician (ND), Doctor of Osteopathy (DO), and Naturopathic Doctor of Osteopathy (NDO)
Patient’s Name ___________________________________________ Age __________
Diagnosis (include description of the patient’s medical or other special dietary needs that restrict the patient’s diet)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
List foods to be omitted from diet: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
List foods to be substituted: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Date _______________ Signature of Medical Authority__________________________
This Institution is an equal opportunity provider.
Medical Statement for Nondisabled Students with Special Needs.doc
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