☐ Short-term (less than 6 months – specify end date: _______________) ☐ Long-term (6+ months or permanent)
$ ____________
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): _________________________ special diet form odsp pdf
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
☐ 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. ☐ Yes ☐ No SECTION 4: DIETARY PRESCRIPTION