Child Allergy Information Form 🩺💙

Child Allergy Information Form 🩺💙

Please fill out this form to provide allergy details for your child.
Child Information
First Name
Last Name
Date of Birth

MonthDayYear
Date
Grade/Class
Parent/Guardian Name
Emergency Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Contact Name
Secondary Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Doctor/Pediatrician Name
Doctor/Pediatrician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email (for form copy)
Parent@email.com
Allergy Types
Allergy Types

Other
Other Allergy Details
Overall Allergy Severity
Symptoms to Watch For
Symptoms to Watch For
Additional Symptom Notes
Medications & Treatments
Medication Name
Ex Benadryl, EpiPen, Cetirizine
Type
Dose / Amount
ex 12.5 mg, 1 tablet
When to Use
Location at school
ex Backpack, nurse office
Special Instructions
ex. Give with water, call parent immediately after administering
Does the child carry an EpiPen or epinephrine auto-injector?
Who is trained to administer the EpiPen
ex School Nurse, Ms. clark (teacher), any staff member
Emergency Action Plan
Step-by-Step Emergency Instructions
1. give Benadryl if mild
Nearest Hospital
Preferred Hospital / Hospital to Avoid
Additional Information
Has your child been diagnosed by a doctor or allergist
Date of Last Reaction

MonthDayYear
Date
History of Anaphylaxis
Foods / Items Allowed (safe alternatives)
Foods/Items to STRICTLY AVOID (Beyond Main Allergens)
Activity Restrictions (If Any)
Additional Notes for Staff to know
Parent/Guardian Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Child Allergy Information Form 🩺💙

Child Information

Allergy Types

Symptoms to Watch For

Medications & Treatments

Emergency Action Plan

Additional Information