Special Diet Form Odsp: Pdf

☐ Yes ☐ No SECTION 4: DIETARY PRESCRIPTION & MONTHLY COSTS (To be completed by prescriber) Check the applicable ODSP approved special diet components and indicate monthly estimated extra cost.

Ministry of Children, Community and Social Services Ontario Disability Support Program (ODSP) SECTION 1: PERSONAL INFORMATION (To be completed by the applicant) | Field | Information | |-------|-------------| | Full Legal Name | _________________________ | | ODSP Member ID | _________________________ | | Date of Birth (YYYY-MM-DD) | _________________________ | | Home Address | _________________________ | | Postal Code | _________________________ | | Telephone Number | _________________________ | | Caseworker’s Name (if known) | _________________________ | SECTION 2: TYPE OF SPECIAL DIET REQUESTED Check all that apply. You must have a medical diagnosis requiring this diet. special diet form odsp pdf

☐ Short-term (less than 6 months – specify end date: _______________) ☐ Long-term (6+ months or permanent) ☐ Yes ☐ No SECTION 4: DIETARY PRESCRIPTION

| Diet Component | Check if required | Monthly Additional Cost ($) | |----------------|------------------|-----------------------------| | Gluten-free | ☐ | $ ______ | | Low Lactose / Lactose-free | ☐ | $ ______ | | Low Sodium (≤1500mg/day) | ☐ | $ ______ | | Low Potassium (Renal) | ☐ | $ ______ | | Low Phosphorus (Renal) | ☐ | $ ______ | | Pureed (Dysphagia) | ☐ | $ ______ | | Liquid / Supplemental (e.g., Ensure, Boost) | ☐ | $ ______ | | High Protein / High Calorie | ☐ | $ ______ | | PKU / Metabolic formula | ☐ | $ ______ | | Other (specify): __________ | ☐ | $ ______ | ☐ Short-term (less than 6 months – specify

Diabetes (Type 1 or 2 requiring insulin or oral medication) ☐ Hypoglycemia (documented blood sugar below 3.9 mmol/L) ☐ Renal Disease (chronic kidney disease, dialysis) ☐ Malabsorption / Celiac Disease (gluten-free required) ☐ Dysphagia (swallowing disorder – requires pureed or thickened foods) ☐ Hepatic Disease (liver failure/cirrhosis) ☐ Severe Food Allergies (life-threatening – specify allergens: __________) ☐ Metabolic Disorder (e.g., PKU, galactosemia – diagnosed by specialist) ☐ Pregnancy (multiple fetuses or documented nutritional risk) ☐ Lactation (breastfeeding with documented low maternal weight) ☐ Other (specify diagnosis & dietary requirement): _________________ SECTION 3: MEDICAL CERTIFICATION (To be completed by a regulated health professional) Eligible professionals: Medical Doctor (MD), Nurse Practitioner (NP), Registered Dietitian (RD), or Pediatrician for children. Patient Diagnosis (ICD-10 code if available): _________________________

(Explain why this specific diet is medically necessary for this patient): Specific Dietary Modifications Required (e.g., gluten-free, low potassium, pureed, high-calorie supplement): Expected Duration of Diet (choose one):

$ ____________