Anaphylaxis/Allergy/Intolerance Food Form

Child's Name*

First NameLast Name

Child's Date of Birth*

Childs Room*

ExplorersDiscoverersInventorsKindergarten

Booking days*

A. ANAPHYLAXIS

Please refer to the Anaphylaxis policy outlined in the parent handbook. You will be required to provide the service with an individual Medical Action management plan, this needs to be signed by a medical practitioner who is treating your child. More information is available at www.education.vic.gov.au/anaphylaxis www.allergysafe.com.au and www.anaphylaxisaustralia.com.au

Has your child been diagnosed at risk of Anaphylaxis?*

YesNo

What Allergen is your child ANAPHYLACTIC to?

Does your child have an Auto Injection device (EpiPen)? Please note that your child cannot attend the service unless they have their Epi-Pen with them. Our preference is for you to leave one Epi-Pen at Merri?*

YesNo

Have you provided Merri with the ANAPHYLACTIC management Action plan?*

YesNo

Other Information - Is there any other information that is important for us to know in regards to your child's nutritional / eating habits? If yes, please comment below

Once we have been provided with your childs ANAPHYLACTIC management Action plan, our Cook and Educators will construct a risk minimisation plan. Educators will consult you for further clarity and needs to be signed once reviewed. This gets altered and updated pending your childs Action plan. Please refer to handbook for more information.

A. ALLERGY

Please refer to the Allergy policy outlined in the parent handbook. You will be required to provide the service with an individual Allergy Action management plan and your childs Medication, this needs to be signed by a medical practitioner who is treating your child. More information is available at www.allergysafe.com.au

Has your child been diagnosed at risk of ALLERGY?*

YesNo

What Allergen is your child Allergic too?

Have you provided Merri with the ALLERGY management Action plan?*

YesNo

Have you provided Merri with the medication listed on the ALLERGY management Action plan?*

YesNo

Other Information - Is there any other information that is important for us to know in regards to your child's nutritional / eating habits? If yes, please comment below

Once we have been provided with your childs ALLERGY management Action plan, our Cook and Educators will construct a risk minimisation plan. Educators will consult you for further clarity and needs to be signed once reviewed. This gets altered and updated pending your childs Action plan. Please refer to handbook for more information.

C. MEDICAL CONDITIONS/INTOLERANCE

Does your child have a Medical Condition/Intolerance related to foods*

YesNo

Diabetes *

YesNo

Coeliac*

YesNo

Salicylates*

YesNo

Food Intolerance*

YesNo

Other*

YesOther

Does your child have a Medical letter for this condition*

YesNo

Does your child require any medication*

YesNo

Once we have been provided with your childs Medical condition/Intolerance linked with foods, our Cook and Educators will construct a risk minimisation plan. Educators will consult you for further clarity and needs to be signed once reviewed. This gets altered and updated pending your childs Action plan. Please refer to handbook for more information.

Other Information - Is there any other information that is important for us to know in regards to your child's nutritional / eating habits? If yes, please comment below

* FOOD LABELLING/PACKAGING/INGREDIENTS

Please note that if your child is safe with the food that may contain trace of allergen. an updated Allergy Reaction Plan or letter from a doctor is needed.

Please provide us with ALL the SAFE foods and food products, including brands and ingredients?

Please provide us with ALL the UNSAFE foods and food products, including brands and ingredients?

Please list any foods that you do use as SUBSTITUTES for the above foods

Is the Allergen food only in the Pure form only*

YesNoOther

Are there any PRESERVATIVES to be avoided*

YesNo

Number of PRESERVATIVE to be avoided

Are there any THICKENER AGENTS to be avoided?*

YesNo

Details of THICKENER AGENTS to be avoided

Are there any STABILISERS to be avoided?*

YesNo

Details of STABILISERS to be avoided

Are there any OTHER foods that are needed to be avoided

Thank you for your time. Menu and food feedback and or any suggestions are always welcomed. We will continue to endeavour to communicate with families about your childs diet whilst at Merri, if anything changes it is important to please let us know.

Huayun Chen

Centre Cook