Student Allergy/Intolerance Name of child …………………………………………………….
My child has no known allergies or intolerances
(please tick if applicable)
or
My child is allergic*/intolerant* to …………………………………………………………….(Please specify)
(please delete as appropriate – see clarification below))
Allergy
Intolerance
Allergic reactions are often mild, but they can sometimes be
very serious.
Symptoms of a food allergy can affect different areas of the
body at the same time. Some common symptoms include:
 an itchy sensation inside the mouth, throat or ears
 a raised itchy red rash (known as hives)
 swelling of the face, around the eyes, lips, tongue
and roof of the mouth
 vomiting
A food intolerance is not the same as a food allergy.
People with food intolerance may have symptoms such as
diarrhoea, bloating and stomach cramps. This may be caused
by difficulties digesting certain substances, such as lactose.
However, no allergic reaction takes place.
Important differences between a food allergy and a food
intolerance include:
 The symptoms of a food intolerance usually occur
several hours after eating the food.
 You need to eat a larger amount of food to trigger an
intolerance than an allergy.
 A food intolerance is never life-threatening, unlike an
allergy
Allergens: Eggs, Milk, Shellfish, Molluscs, Fish, Peanuts, Sesame, Soya, Sulphur Dioxide,
Nuts, Cereals containing gluten, Celery, Mustard, Lupin, Other.
Please specify details of your child’s typical reaction to (each) food allergen.
Can he/she tolerate a very small amount of the allergen(s)?
Parents/Carer’s name ……………………………………………………..(Please print)…………………………………..……(signature)
Date…………………………….