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BVS Allergy Questionnaire
If your child has allergies, please complete this form with the assistance of your child's doctor.
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* Indicates required question
Email
*
Your email
Today's Date
*
MM
/
DD
/
YYYY
Child's Name
*
Your answer
Child's DOB
*
MM
/
DD
/
YYYY
Gender Identity
*
Female
Male
Prefer not to say
My child has allergies to:
*
Peanuts
Tree Nuts
Milk
Eggs
Soy
Gluten/Wheat
Fish/Shellfish
Dairy (not baked)
All dairy
Chocolate
Honey
Honeydew/Melon
Cashews
Bees
Wasps
Grass
Pollen
Cats
Dogs
Penicillin
Aspirin
Ibuprofen
Paracetamol
Latex
My child has no known allergies.
Other:
Required
Any allergies not listed in the list above:
Your answer
Describe your child's allergic reaction
mild: runny nose, itchy/red eyes, frequent sneezing
moderate: hives, intense itching, scratchiness to throat
severe: difficulty breathing, wheezing, throat tightness, lip swelling, high risk for anaphylactic shock
triggers asthma attack
Comments about allergic reaction:
Your answer
Has your child every had an anaphylactic reaction?
*
Yes
No
If yes, please describe when/how many times/trigger:
Your answer
Does your child take medication for this allergy? If yes, please list medication. (Name of medication, frequency, used at home or school or both, etc.)
Your answer
Is there a need to keep medication at school for this allergy? (If yes, please fill out an authorization form at school.)
Yes
No
Clear selection
If yes, where would you like your child's medication to be kept?
office
in classroom
in child's backpack
Clear selection
Does your child have an EpiPen (self administered injection of epinephrine)?
*
Yes
No
If yes, where would you like your child's EpiPen to be kept?
In office
In classroom
In backpack
Clear selection
Are there any limitations/restrictions of physical activities at school due to allergies? If yes, please specify.
Your answer
A copy of your responses will be emailed to the address you provided.
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