New OPPHS 3/05 App. HSAC 4/21/05 Purpose of Form: Above 95% Below 5% Low Lab. Values Food Allergy/Sensitivity Low Food Eating Frequency Score INDIVIDUAL NUTRITION PLAN CENTER AND CLASS #: __________________________ DATE: _____________________ CHILD’S NAME: _________________________________ AGE: _____________________ HEALTH INFORMATION LAB. FINDINGS Aug/Sept Dec April Date: Hgb/Hct Ht Wt % Ht Wt % Ht Wt % Recheck: Y or N Recheck Results: *ATTACH COPY OF HEIGHT/WEIGHT GRAPH. Date: Hgb/Hct *ATTACH COPY OF PHYSICAL IF STATEMENTS PERTAINING TO HGB = 11 & above Hct. = 34 & above HT/WT, LAB. IS MADE. SIGNIFICANT HEALTH CONDITIONS: _________________________________________________________ _________________________________________________________________________________________ SPECIAL ACCOMODATIONS THE FACILITY MUST PROVIDE: _____________________________________ _________________________________________________________________________________________ IS CHILD CURRENTLY UNDER THE CARE OF A PROFESSIONAL FOR ANY NUTRITION RELATED CONCERNS? Y OR N WEIGHT/HEIGHT, FOOD ALLERGIES ANEMIA, ETC. FOOD ALLERGY INFORMATION (circle all that apply) DOCUMENTED FOOD ALLERGIES/SENSITIVITY: Y OR N LIST TYPE OF FOODS: _____________________________________________________________________ _________________________________________________________________________________________ DOCTOR’S NOTE AVAILABLE: Y OR N *If no, give parent a copy of the *Medical Statement for Children Without Disabilities Requesting Special Foods in the Child Nutrition Programs to be returned to center. Type of Reaction to Expect: Itching of lips or mouth Swelling of throat Nausea Vomiting Abdominal cramps Belching Diarrhea Constipation Hives Eczema Asthma Runny nose Sneezing Other: List: Severity of Symptoms: Severe Moderate Mild Same reaction in raw and cooked foods? Y OR N How long after eating food do symptoms occur? ________________ Special adaptions needed: Group time _____________________________________ Self-Select _______________________________________________ Outdoor time ____________________________________________________________________________________________ Meal time: ______________________________________________________________________________________________ Special equipment: ______________________________ Special foods: ____________________________________ Consistency modification: ___________________________ Other: _________________________________________ _______________________________________________________________________________________________ Describe training that has been given to all pertinent staff by appropriate persons: ______________________________________________ _______________________________________________________________________________________________________________ Signatures and date of all attending training: __________________________________________________________ ____________________________________________________ __________________________________________________________ ____________________________________________________ __________________________________________________________ ____________________________________________________ NUTRITIONAL INFORMATION Does child receive WIC? Y OR N If no, why? ________________________________________________________ Significant nutrition related data: _______________________________________________________________ ___________________________________________________________________________________________ _______________________________________________________________________________________ Food Eating Frequency Score _________________ Attach a copy of the *Meal Time Observation completed by I have reviewed the following checked teaching staff to form. plans with the parent/caregiver: ____________________________________________ Family Advocate Signature Plan of Care 1 Plan of Care 2 * All items with an * will require that a copy of another form must be Plan of Care Low Hgb/Hct, Anemia attached. Good Nutrition FA initials _____________ White copy in child’s folder, and send yellow copy to Nutrition Specialist by October 31 or the month following the child’s 1 enrollment and/or at the time nutritional at risk is determined. PLAN OF CARE Center/Class ___________________________ Child’s name____________________________ Please check all that apply. Check only when completed. Date: ____________________________________ PLAN FOR UNDER 5% OVER 95% PLAN FOR LOW HGB/HCT PLAN (1) PLAN (2) GOOD NUTRITION ANEMIA Eats very little from a food group or excessively from the sweet or fat food group. 1. . Complete Individual Nutrition 1. Complete Individual Nutrition 1. Complete Individual Nutrition 1. . Complete Individual Plan.. Plan.. Plan. Nutrition Plan. ______ Yes ______ Yes ______ Yes ______ Yes 2. Recheck within 30 days. 2. List the handouts given. 2. List the handouts given. 2. Head Start will record ______Yes (see list for appropriate handouts) (see list for appropriate handouts) height and weight. Date: 3. Consult with caregiver. 3. List of handouts given. ______ Yes (see list for appropriate 4. List the handouts given. handouts (see list for appropriate handouts) Head Start: These are the things we will do. Provide information to parent Provide handouts for Provide handouts for Provide handouts for about iron rich foods. healthy eating habits. healthy eating. healthy eating. Assist parent by reminding of Provide assistance to Provide minimum daily Provide other recheck. family to obtain services meal requirements for information as requested. from a professional if children ages 3-5. necessary. Assist in transportation needs. Provide information Provide information Provide information about WIC, if child is age about active play activities about WIC, if child is age eligible. for children. eligible. Provide information about Other: Provide information Give the Food Guide WIC, if child is age eligible. about WIC if child is age Pyramid for Kids as a eligible. resource. Other: Other: Other: Please check if parent is not concerned with child’s weight/health concerns. Parent Initials _______________ Date ______________ Family Advocate Initials ___________ Parent Responsibilities Parent may choose from this list Provide a diet that is high in Offer well-balanced Offer regular, well- Offer regular, well- iron. meals. balanced meals. balanced meals. Follow the advice of the Provide frequent, Provide planned snacks Provide planned medical professional. planned snacks. low in fat, sugar, and salt. snacks low in fat, sugar, and salt. Consider giving an over the Encourage child to be Encourage child to be Encourage child to be counter multivitamin with iron. involved in active play. involved in active play. involved in active play. Offer well balanced, regular, Start taking a multi- Evaluate family policy for Evaluate family policy for planned meals. vitamin, if child is not keeping non-nutritious foods in keeping non-nutritious foods currently taking one. the house. (if only healthy foods in the house. (if only healthy are available then those will be foods are available then the choices made) those will be the choices made) Apply for WIC if not currently Apply for WIC if not Work on different Apply for WIC if not receiving. currently receiving. cooking styles. (bake instead currently receiving. of fry, etc.) Apply for WIC if not currently receiving. White copy in child’s folder, and send yellow copy to Nutrition Specialist by October 31 or the month following the child’s 2 enrollment and/or at the time nutritional at risk is determined.
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