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Allergy Assessment Form

All allergies requiring medication and/or special meal requirements must be documented by the child’s physician and you will need to provide us with a copy of that document.
Child Information*
Child's Name Date of Birth Parent/Guardian Phone
- My Child has NO known allergy
- My Child HAS an allergy (see below):
1. Food Allergy (Select Applicable Foods)
- Peanuts Peanut/Nut Butter
- Peanut or Nut Oils
- Soy Products
- Milk
- Eggs
- Fish/Shellfish
- Tree nuts (walnuts, etc.)
Others
How many times has your child had a reaction?
- Never
- Once
Comments
What are the signs and symptoms of your child’s allergic reaction? Please be specific!
2. Bee or Insect Allergy
To your knowledge, is your child allergic to bee stings?
- Yes
- No
When was the last reaction?
Describe Reaction in Detail:
Has your child received EpiPen or other injection as treatment:
- Yes
- No
3. Asthma
Severity?
- Mild Intermittent
- Mild Persistent
- Moderate
- Severe
Action/Medication to take:
(Please note that an allergy cannot be “removed” unless there is a note from the physician)
Parent/Guardian (Signature):*
First Last
Date
MM slash DD slash YYYY
Email*
Comments
This field is for validation purposes and should be left unchanged.

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