FOOD ALLERGY INFORMATION
FOOD ALLERGY INFORMATION
Student’s Name: ______________________________________________________
Student is Allergic to: __________________________________________________
Symptoms seen with past allergic reaction(s): _______________________________
__________________________________________________________________________________________________________________________________________
Treatment of past allergic reaction(s):
_____ Benadryl
_____ EpiPen or EpiPen Jr.
_____ None-observation only
_____ Other (please explain: ____________________________________________)
Nature of allergic reaction:
_____ Ingestion of food containing the allergen may cause an allergic reaction
_____ Physical contact (touching) with this allergen may cause an allergic reaction
_____ Airborne contact with the allergen may cause an allergic reaction
EATING LUNCH AT SCHOOL
List of food products that need to be avoided: _______________________________
_____________________________________________________________________
Student will:
_____ Bring lunch from home
_____ Eat cafeteria food
_____ Bring lunch or eat cafeteria food
If student eats cafeteria food will food choices need to be monitored?
_____ Yes, parent will review the menu and discuss food choices with the student
_____ No, student will make his/her own food choices
(CAFETERIA MANAGER WILL BE NOTIFIED OF INDIVIDUAL FOOD ALLERGIES)
CLASS PARTIES/SNACK TIME
What foods can be eaten during class parties or snack time?
_____ Student will bring his/her own food from home for parties or snack time
_____ Student can eat only store bought snacks with an ingredient label that can be
checked by the teacher or nurse
_____ Student can eat home baked products such as cookies/cupcakes or bulk
snacks without an ingredient label
CLASS PARTIES/SNACK TIME: PEANUT OR NUT ALLERGY
Can student eat store bought snacks with an ingredient label that says, “May contain peanuts” or “Made on equipment that also processes peanuts and nuts”?
_____ No
_____ Yes
Additional Comments:___________________________________________________
Parent Signature: ____________________________ Date: ____________________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- dog food allergy relief fast
- food allergy reactions
- food allergy symptoms in adults
- food allergy reactions on face
- food allergy icd 10 code
- food allergy unspecified icd 10
- food allergy skin rash
- food allergy guidelines
- icd 10 code for food allergy panel
- pediatric food allergy guidelines
- possible food allergy icd 10
- food allergy blood test accuracy