2. The Major Life Activity or Major Bodily Function affected by the disability; 3. The food or to be omitted from the participant’s diet; and, 4. The food or choice of foods that must be substituted Slide 10 Medical Statement for Participants with Disabilities For use when a participant has a disability that requires the elimination of a mandatory meal pattern component, a modification to texture, a reduction of portion size or a change in meal frequency. This form must be signed by a licensed physician (Medical Doctor [MD] or Doctor of Osteopathy [DO], only.) (click)Part 1 is to be completed by Sponsor or Parent/Guardian (click)Name of participant use – the participants full legal name (click)Part 2 is to be completed only by a licensed physician: medical doctor (MD) or Doctor of Osteopathy (DO) (click) In this section Diagnosis needs to include description of the patient’s disability and the major life activity or major bodily function affected by the disability.
2. The Major Life Activity or Major Bodily Function affected by the disability; 3. The food or to be omitted from the participant’s diet; and, 4. The food or choice of foods that must be substituted Slide 10 Medical Statement for Participants with Disabilities For use when a participant has a disability that requires the elimination of a mandatory meal pattern component, a modification to texture, a reduction of portion size or a change in meal frequency. This form must be signed by a licensed physician (Medical Doctor [MD] or Doctor of Osteopathy [DO], only.) (click)Part 1 is to be completed by Sponsor or Parent/Guardian (click)Name of participant – use the participants full legal name (click)Part 2 is to be completed only by a licensed physician: medical doctor (MD) or Doctor of Osteopathy (DO) (click) In this section Diagnosis needs to include description of the patient’s disability and the major life activity or major bodily function affected by the disability.
special-dietary-needs-presentation-notes.docx