Special Diet Form Odsp Pdf [upd] Direct

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.

☐ Short-term (less than 6 months – specify end date: _______________) ☐ Long-term (6+ months or permanent) special diet form odsp pdf

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): _________________________ Ministry of Children, Community and Social Services Ontario

(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): Ministry of Children

| 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): __________ | ☐ | $ ______ |