ALLERGIC REACTION MANAGEMENT FORM
Approved by Director: 09/01/2014
Scheduled Review Date: 00/01/2016
ALLERGIC REACTION
MANAGEMENT
INFORMATION FORM
Participant Name : _______________________________________________________________________
This form must be completed by the participant’s parent/guardian if the participant has ever suffered an
allergic reaction to insect bites, food groups or additives, plant pollens, toxins (eg spider, snake bites),
detergents or cleaning agents or any other triggers. This information is of vital importance in the event of an
allergic reaction as it will assist in the speedy provision of correct treatment.
What is the participant allergic to? __________________________________________________________
What are the signs and symptoms of the participant’s reaction? ____________________________________
Has the participant at any time suffered from: (please tick)
 A localised reaction (any rash, itching, swelling at the site the poison has entered)
 A systemic reaction (any rash, itching, swelling away from the site the poison has entered)
 An anaphylactic reaction (sever breathing problems, swelling of the body, emergency situations)
What medication does the participant take (if any) for prevention against allergic reactions?
______________________________________________________________________________________
Please note: All medication for the treatment of this reaction must be brought by the participant and be noted
on the medical form.
What treatment is followed for the participant if an allergic reaction occurs?
______________________________________________________________________________________
______________________________________________________________________________________
Five Vital Questions
1. Does the person suffer a systemic reaction to their allergy?
2. Does the person suffer an anaphylactic reaction to their allergy?
3. Is there a family history of anaphylaxis?
4. Has the person ever been hospitalised due to an allergic reaction?
5. Is adrenaline (adrenaline injection, medi-epihaler, epi-pen) administered
to the person when they suffer from an allergic reaction?
 Yes
 Yes
 Yes
 Yes
 No
 No
 No
 No
 Yes
 No
If yes has been answered to any of these questions, please read and sign below:
I understand that my son/daughter’s involvement in La Luna Youth Arts may mean he/she is remote from
immediate medical help. In consultation with my child’s doctor, I have provided enough written information to
deal appropriately with an allergic reaction.
Is extra information attached?
 Yes
 No
Signed ___________________________________________
(parent/guardian)
Date __________________
PRIVACY STATEMENT: All information is confidential & for use by La Luna Youth Arts to ensure the safety and wellbeing of your child or yourself.
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