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California Department of Education Nutrition Services DivisionChild Nutrition Programs CNP 925 (Rev. 8/17) Page 1MEDICAL STATEMENT TO REQUEST SPECIAL MEALS AND/OR ACCOMMODATIONS 1. School or Agency
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Read the instructions provided on the medical statement form.
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Fill in your personal information such as name, date of birth, address, and contact information.
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Provide details of your medical history including any current medications, allergies, and pre-existing conditions.
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Include the reason for filling out the medical statement form and any relevant medical information.
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Make sure to sign and date the form before submitting it to the appropriate party.

Who needs medical statement form for?

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Individuals applying for certain jobs that require medical clearance.
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Students participating in sports or other extracurricular activities.
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Patients seeking medical treatment or procedures.
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Travelers applying for specific visas or permits.
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The medical statement form is used to provide important information about an individual's medical history and current health status.
Anyone who is seeking medical treatment or participating in a medical program may be required to file a medical statement form.
To fill out a medical statement form, you will need to provide accurate information about your medical history, current health status, and any medications you are taking. It is important to be thorough and honest when completing the form.
The purpose of the medical statement form is to provide healthcare providers with essential information about a patient's medical history and current health status. This helps ensure that the patient receives appropriate care and treatment.
The medical statement form typically requires information about past medical conditions, current medications, allergies, surgeries, family medical history, and contact information for healthcare providers.
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