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INDIVIDUAL NUTRITION PLAN

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INDIVIDUAL NUTRITION PLAN Powered By Docstoc
					                                                                                                                               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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