• Modified diet care plan

  • CONFIDENTIAL

    To be completed by the DOCTOR OR DIETITIAN and the PARENT/GUARDIAN.
    This form is to be used where a child has a proven history of food allergy or intolerance or requires a special diet for a proven medical condition.
    This information is confidential and will be available only to supervising staff and emergency medical personnel.

  • (Family name) (First name)
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • (eg soy products instead of standard dairy for lactose intolerance).
  • (eg meals at particular times or intervals for health reasons).
  • Please indicate whether the person can report symptoms, the time period over which symptoms might emerge and the severity of the anticipated reaction.
  • First aid response to signs and symptoms of an allergic reaction/intolerance to a food or other substance.

    Please complete the first aid action plan on the back of this form. If the reaction is severe, an anaphylaxis care plan, including an emergency first aid response, will be required from the treating medical practitioner.
  • This plan has been developed for the following services : Long Day Care

  • AUTHORISATION AND RELEASE

  • Date Format: MM slash DD slash YYYY
  • I have read, understood and agreed with this plan and any attachments indicated above.
    I approve the release of this information to supervising staff and emergency medical personnel.
  • (Family name)(First name)
  • Date Format: MM slash DD slash YYYY
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