Community Colleges of Spokane



-28204-9652000Spokane Head Start /ECEAP/EHSNUTRITION DIET REQUEST: FOOD ALLERGY/INTOLERANCESite/room FORMTEXT ?????FSC FORMTEXT ?????Child’s name FORMTEXT ?????Date of birth (mm/dd/yyyy) FORMTEXT ?????Parent/guardian FORMTEXT ?????Phone FORMTEXT ?????Cell/work FORMTEXT ?????Health Care Provider treating food allergy/intolerance/reaction FORMTEXT ?????Phone FORMTEXT ?????Do you think your child’s food allergy may be life-threatening? FORMCHECKBOX No FORMCHECKBOX YesDid your child’s health care provider tell you the food allergy may be life-threatening? FORMCHECKBOX No FORMCHECKBOX Yes(If YES, an Individual Health Plan will need to be in place before your child attends school.)CURRENT STATUS Check the foods that have caused an allergic reaction: FORMCHECKBOX Fluid milk FORMCHECKBOX Milk cooked in foods FORMCHECKBOX Milk/cheese-based soup FORMCHECKBOX Cheese FORMCHECKBOX Cheese cooked in foods FORMCHECKBOX Yogurt FORMCHECKBOX Cottage cheese FORMCHECKBOX Cream cheese FORMCHECKBOX Margarine FORMCHECKBOX Trace amounts of milk in foods such as bread FORMCHECKBOX Mayonnaise FORMCHECKBOX Eggs FORMCHECKBOX Pancakes (contains milk, egg and soy) FORMCHECKBOX French toast (contains milk, egg and soy) FORMCHECKBOX Waffles (contains milk, egg and soy) FORMCHECKBOX Muffins (contains milk, egg and soy) FORMCHECKBOX Eggs cooked in other foods.Please list FORMTEXT ????? FORMCHECKBOX Soy products including soy oil, hydrolyzed or textured vegetable protein (H or TVP), soy sauce, soybean flour, etc. FORMCHECKBOX Soy Cheese FORMCHECKBOX Soy Yogurt FORMCHECKBOX Wheat FORMCHECKBOX Gluten FORMCHECKBOX Peanuts FORMCHECKBOX Foods manufactured in a plant that processes peanut containing foods FORMCHECKBOX Peanut or nut oils FORMCHECKBOX Peanut or nut butter FORMCHECKBOX Peanut flour FORMCHECKBOX Tree nuts (walnuts, almonds, pecans, etc.) FORMCHECKBOX Fish/shellfish FORMCHECKBOX Citric acid FORMCHECKBOX Citrus fruits including oranges, canned Mandarin oranges and grapefruit FORMCHECKBOX Pineapple FORMCHECKBOX Berries including strawberries, blueberries, raspberries or blackberries FORMCHECKBOX Juices including orange, pineapple, apple or grape FORMCHECKBOX Tomatoes including sauce and ketchupPlease list any others FORMTEXT ?????What do you use as a substitute for milk, cheese, or yogurt? FORMTEXT ?????TRIGGERS, SYMPTOMS, AND ACTION PLANMy child will have a reaction (Check all that apply) FORMCHECKBOX Eating foods FORMCHECKBOX Touching foods FORMCHECKBOX Smelling foods FORMCHECKBOX Other, please explain FORMTEXT ?????How quickly do the signs and symptoms appear after exposure to the food(s)? FORMTEXT ?????Seconds FORMTEXT ?????Minutes FORMTEXT ?????Hours FORMTEXT ?????DaysWhat are the signs and symptoms of your child’s reaction? FORMTEXT ?????What should staff do? FORMTEXT ?????Do you want staff to notify you? FORMCHECKBOX Immediately FORMCHECKBOX Upon pick up FORMCHECKBOX Other FORMTEXT ?????Parent/guardian signature FORMTEXT ?????Date FORMTEXT ?????Original in child’s fileCopy to Nutrition SpecialistCopy to parentFor staff use only FORMCHECKBOX Health Specialist notified FORMCHECKBOX IHP in place FORMCHECKBOX IHP needed ................
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