You are on page 1of 1

School Name School Year

Individualized School Healthcare Plan (Group C) 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. Sucraid (enzyme replacement to aid in digestions of sugars) is to be taken daily before all Medications meals and snacks. Sucraid is only able to assist with digesting up to 25 grams of sucrose per meal. ________________________ can have starch-containing foods in small amounts, but cannot tolerate large quantities. He/She should avoid foods like cookies, or cake which contain large amounts of sugar and starch. He/she is aware of his/her condition, and is generally able to identify which foods to avoid. If not managed properly, this condition can lead to malnutrition and severe dehydration.

Other Pertinent Information

Procedures for Health and Diet Management at School 1) Student will go to the nurse or office to take Sucraid before lunch, special classroom treats or snacks. 2) 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. 3) If there is a question about whether student can have a particular food, the teacher will contact the parent.

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

Date Date Date Date