Allergy Information
Student Name:
Grade:
Student DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does your child have any allergies?
Yes
No
If yes, please list all known allergies (food, environmental, insect stings, medication, etc.):
What type of reaction does your child experience? (check all that apply)
Rash/hives
Swelling
Difficulty breathing
Stomach pain/nausea/vomiting
Other
How severe are your child's allergies?
Mild
Moderate
Severe (life-threatening/anaphylaxis)
Back
Next
Has your child ever required emergency treatment (such as an EpiPen, ER visit, or ambulance) for an allergic reaction?
Yes
No
If yes, please describe:
Does your child have a prescribed EpiPen or other emergency medication?
Yes
No
If yes, where should it be kept during the school day?
With student
Nurse's office
Classroom teacher
Other
Are there specific foods, snacks, or activities your child should avoid at school?
Yes
No
What steps do you recommend we take if your child has an allergic reaction at school?
Is there any additional information about your child's allergies or health needs that the school should know?
Parent/Guardian Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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