Allergy Plan

Allergy or Dietary Restriction Form
Child's Name*
Date of Birth*

MonthDayYear
Health Disclosure - My child's restriction is a(n):

AllergyDietary RestrictionReligious Preference
If your child has no known allergies please indicate so here:
Description of child's special dietary restriction:
Description of Allergy/Condition (What physical symptoms does the child exhibit when this food is ingested or if the child comes in contact with this item?)
Date of last reaction

MonthDayYear
Action Taken
Please select all allergy symptoms child has experienced:
Mouth: Itching and swelling of lips, tongue or mouthThroat: Itching and/or sense of tightness in the throat; hacking coughSkin: Hives; itchy rash and/or swelling around the face, arms or legsStomach: Nausea, abdominal cramps, vomiting, diarrheaLung: Shortness of breath; repetitive coughing; wheezingHeart: "Thready" pulse; passing out
Treatment Plan: (Specific action to be taken if child comes in contact with item)
Name of Medication
Prescription Number:
Expiration Date

MonthDayYear
Location of medication in building:

Can be kept in school officeShould be kept in classroom for urgent administration
Dosage instructions
Route of delivery:
I hereby request Primrose, through its designated authority, to administer medication according to the above instruction. I release the school and any school employee from any liability for administering this medication.
Signature

Clear
Date*

MonthDayYear
Form must be updated annually or anytime information verified by a physician changes.
Should be Empty:

Allergy or Dietary Restriction Form

Please select all allergy symptoms child has experienced: