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School Name School Year

Individualized School Healthcare Plan (Group A-w/out Sucraid) CONFIDENTIAL
Name STUDENT INFORMATION DOB Grade PARENT/GUARDIAN INFORMATION Phone Home Teacher

Name(s)

Mobile

Condition Allergies

Congenital Sucrase-Isomaltase Deficiency (CSID)

__________________ has an enzyme deficiency which prevents his/her body from properly Brief Medical digesting sugars and starches (including wheat, corn, potatoes, and rice). Eating too much of these foods causes digestive problems, including abdominal cramping, gas, bloating, Background vomiting and/or diarrhea.

Medications

NO MEDICATIONS ARE AVAILABLE AT THIS TIME

________________________ cannot have starch-containing foods in any amount. This includes most gluten-free foods as they typically contain a higher starch content than foods Other made from grains. He/she is aware of his/her condition, and is generally able to identify Pertinent Information which foods to avoid. If not managed properly, this condition can lead to malnutrition and severe dehydration. Procedures for Health and Diet Management at School 1) The teacher will notify parent prior to upcoming class celebreations or events involving food in the classroom so that parent can provide an alternative food, if needed. 2) If there is a question about whether student can have a particular food, the teacher will contact the parent. 3) Parent will provide school lunches for student at this time.

Nurse's Signature Parent Signature Doctor's Signature Doctor's Name Principal's Signature Phone

Date Date Date Date