JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Food Allergy/Anaphylaxis Information Form
Please complete regarding your child's listed food allergy
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Student First and Last name
*
Your answer
Parent/Guardian phone number:
Your answer
Do you think your child's food allergy may be life threatening?
*
Yes
No
Check the foods that have caused an allergic reaction
*
Peanuts
Fish/Shellfish
Soy Products
Tree Nuts (walnuts, almonds, pecans, etc.)
Eggs
Milk
other
Required
If "other" is checked above, please list allergies
Your answer
How many times has your child had a reaction?
*
Never
Once
More than once , please explain below
If checked "more than once" for the above reaction, please explain
Your answer
When was the last reaction?
*
Your answer
Are the food allergy reactions:
Staying the same
getting worse
getting better
Clear selection
What has to happen for your student to react to the problem food? (Check all that apply)
*
Eating foods
Touching foods
Smelling foods
Other, please explain below
Required
If "other" checked for above question, please explain here
Your answer
What are the signs and symptoms of your child's allergic reaction? (Please be specific: include the things the child may say)
*
Your answer
How quickly do the signs and symptoms appear after exposure to the food(s)?
seconds
minutes
hours
days
Clear selection
Has your child ever needed treatment at a clinic or hospital for the allergic reaction?
*
Yes
No
Does your child understand how to avoid foods that cause allergic reactions?
*
Yes
No
What treatment or medication has your health care provider recommended for use in an allergic reaction
*
Your answer
Have you used the treatment?
*
Yes
No
Does your child know how to use the treatment?
*
Yes
No
Please describe any side effects your child has experienced with the treatment
Your answer
If medication is to be available at school, have you had the doctor complete the form (MED-1)
Yes
No, I need to get the form, have it completed by our doctor, and return it to school nurse
I will not be providing the emergency medication to the school
Clear selection
What would be helpful at school to help your child avoid food problems?
Your answer
I give consent to share, with the classroom teachers/school , that my child has a life-threatening food allergy.
*
Yes
No
Parent/Guardian Signature and date:
*
Your answer
Do you have any questions for the school nurse?
*
Yes
No
Reviewed by RN signature and date:
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of School District of Philadelphia.
Report Abuse
Forms
