ALLERGY QUESTIONNAIRE
You have indicated that your student is allergic to a food, plant, drug or insect. The school needs to
know how severe this allergy is so that we can help protect your child at school. Please complete the
following form and return it to the Health Room at your student’s school. Thank you for your
assistance.
Student Name: ________________________________________________________ Date of Birth: ____________
School: ________________________________________________________________ Grade: ____________________
My child is allergic to (check all that apply, add more as needed)
□ bee stings
□ medications: specify: ______________________________________
□ tree nuts
□ peanuts
□ eggs
□ milk/milk products
□ fish
□ shell fish
□ other (list) _________________________________________________________________________________
_________________________________________________________________________________
Allergic response is as follows:
□
mild: may have rash, itching, stomachache. Response is not life threatening
□
moderate: hives, but no respiratory symptoms: not life threatening
□
severe: swelling of face, tongue, or throat, difficulty breathing, loss of consciousness,
respiratory arrest. This is a life-threatening response which requires medication, 911
call and emergency care.
□
other: (explain) _____________________________________________________________________
Treatment:
□
□
□
□
□
what is needed to treat the student’s allergy?
no treatment is needed
if a bee sting, remove stinger, and ice area. No further treatment needed.
medication is needed: specify __________________________________________________________
Epi-pen is required
other: (explain):________________________________________________________________________
NOTE: If emergency medication is needed for your student’s allergic response, this medication
must be brought to school, along with a physician’s order and parental authorization. An
emergency care plan must be written with the School Nurse.
All of the above must be in place before the student can attend school. No medications are
given at school unless they are provided by the parent and appropriate authorization form is
completed for each medication needed.
Parent Signature: _____________________________________________________ Date: ______________
Please Print Name: _____________________________________________ Relationship: ___________
Address: _______________________________________________________ Phone: __________________
HS-11/20/08