Beaufort-Jasper Eoc Head Start

Medical Diet Documentation Form

Child's Last Name:*
Child's Middle Name:
Child's First Name:*
What program option are you registering for?*

Diet regiment/restriction:
List all restricted foods:
Medical Reason:
Alternate foods or supplements to be provided in place of restricted foods (this is required when a food group is being restricted from the diet):
Other Instructions:
How long will the child require the above diet restriction/regimen?
List any vitamin/mineral supplements (i.e. Pedi sure, Ensure, Boost) or other pertinent medication the child is taking:
Is the child being followed by a Registered/Licensed Dietitian?*
If yes, please list the name and phone number:
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