Exhibit-Food Allergy History Form
ALLERGY HISTORY FORM
(Please return to the school nurse)
Dear Parent/Guardian of:_______________________________________________Date:________________
According to your child’s health records, he/she has an allergy to:
Please provide us with more information about your child’s health needs by responding to the following questions and returning this form to the school office.
- When and how did you first become aware of the allergy?
- When was the last time your child had a reaction?
- Please describe the signs and symptoms of the reaction.
- What medical treatment was provided and by whom?
- Please describe the steps you would like us to take if your child is exposed to this allergen while at school.
If medication is required while your child is at school, the enclosed Emergency Action Plan (EAP) and medication forms must be completed by a licensed medical provider and parent/guardian.
Parent/Guardian Signature: ____________________________________________ Date: ______________________
Print Name: ________________________________________________
Reviewed: January 18, 2011
Adopted: January 18, 2011