Allergy Form

Allergy Form
(This form is to be used for a diagnosed food allergy only, not a food intolerance)
Child's Name
Date of Birth

MonthDayYear
Date
Allergy To:
(If no known allergy you can put a N/A and sign the bottom of form)
ASTHMATIC (Circle) YES NO

YesNo
AN INHALER IS TO BE KEPT AT CHILDARE IF PRESCRIBED, IF TOO YOUNG FOR INHALER BREATHING MACHINE IS TO BE BROUGHT INTO CHILDCARE

My child may experience one or more of the following:
SYMPTOMS: (Please check)

Itching & Swelling of the lips, tongue or mouthItching and/or sense of tightness in the throat, hoarseness, and hacking coughHives, itchy rash, and/or swelling abut the face or extremitiesNausea, abdominal cramps, vomiting, and/or diarrheaShortness of breath, repetitive coughing, and/or wheezing”Thready” pulse, “passing out”
PHYSICIAN'S NAME
If ingestion is suspected, give

Medication/doseCourse of action
PARENTS SIGNATURE

Clear
PHONE NUMBER
Email
example@example.com
DATE_

MonthDayYear
Date
I give permission for Champion Kidz Childcare LLC staff to administer the above medication if necessary, and follow the course of action as directed by the above-named physician.
FOR CHILDREN WITH MULTIPLE FOOD ALLERGIES, USE ONE FORM FOR EACH FOOD
Should be Empty: