Health Related Request for Accommodations to Foods Lab

Home
Online forms
Health Related Request for Accommodations to Foods Lab

Health Related Request for Accommodations to Foods Lab

For Medical Healthcare Provider: The student below has requested special dietary arrangements at Messiah College. Your documentation of the student’s dietary requirements or restrictions will be used by a registered dietitian to develop a meal plan or lab activities that best meets the student’s needs. Please provide medical documentation that is complete and supports the request so that we may best meet the nutritional needs of this student. Thank you.

1. Student Name:

2. Date of Birth:

3. Patient's diagnosis and related ICD-9 or DSM-IV code(s):

4. Current treatment plan including medications, therapies and interventions:

5. Please describe the patient's food restrictions or requirements, including the level of avoidance needed for each food or ingredient, by checking all levels which apply:

Food or ingredient to be avoided	Degree of avoidance needed: Cannot consume	Cannot touch or work with	Cannot be in the same room at the same time	Cannot be in a room which contained the food recently
Food or ingredient to be avoided 1	Degree of avoidance needed: Cannot consume 1	Cannot touch or work with 1	Cannot be in the same room at the same time 1	Cannot be in a room which contained the food recently 1
Food or ingredient to be avoided 2	Degree of avoidance needed: Cannot consume 2	Cannot touch or work with 2	Cannot be in the same room at the same time 2	Cannot be in a room which contained the food recently 2
Food or ingredient to be avoided 3	Degree of avoidance needed: Cannot consume 3	Cannot touch or work with 3	Cannot be in the same room at the same time 3	Cannot be in a room which contained the food recently 3
Food or ingredient to be avoided 4	Degree of avoidance needed: Cannot consume 4	Cannot touch or work with 4	Cannot be in the same room at the same time 4	Cannot be in a room which contained the food recently 4

6. Please attach pertinent supporting data documenting the medical or dietary condition (i.e. History and physical, progress notes, lab data, allergy testing, etc.)

7. Provider's Name

8. Provider's Specialty

9. Provider's Address

10. Signature:

11. Date:

12. Student email: Required