Peregrine School Student Food Allergy & Intolerance Form
Page 1 of 3
Student Food Allergy and Intolerance Form
This form allows our staff to be well-informed regarding students with medically verifiable food allergies and intolerances. If
your child has food allergies or intolerances, please have the completed form signed by your child’s physician or allergist prior to
returning to the office. All parents/guardians of children with allergies and intolerances must also arrange a meeting with their
child's Head Teacher and, if desired, the School Chef.
For students who do not have food allergies and intolerances, please complete the top portion and the first two questions, then
simply sign yourself and return. Thanks!
Student Name:
Date of Birth:
Parent/Guardian:
Home Phone:
Today’s Date:
Work:
Cell:
Primary Healthcare Provider:
Phone:
Allergist:
Phone:
Allergies*
*Food intolerances have also been included below, please fill out/adapt the following questions to help us understand your
child’s needs.
a. Does your child have a diagnosis of an allergy from a healthcare provider?:
☐No ☐Yes
b. Does your child have a diagnosis of a food intolerance from a healthcare provider?:
☐No ☐Yes
c. History and Current Status
i. What is your child allergic or medically intolerant to?
☐Peanuts
☐Eggs
☐Dairy
☐Latex
☐Gluten
☐Soy
☐Insect Stings
☐Fish/Shellfish
☐Chemicals
☐Vapors
☐Tree Nuts (walnuts,
pecans, etc)
☐Other:
ii. Age of student when allergy/intolerance first discovered:
iii. How many times has student had a reaction? ☐Never ☐Once ☐More than once, explain:
iv. Explain their past reaction(s):
v. Symptoms:
vi. Are the food allergy/intolerance reactions: ☐Same ☐Better ☐Worse
d. Trigger and Symptoms
i. What are the early signs and symptoms of your student’s allergic reaction? (Be specific;
include things the student might say.)
ii. How does your child communicate his/her symptoms?
iii. How quickly do symptoms appear after exposure to food(s)? _____secs._____mins.
Updated 07/2015
Peregrine School Student Food Allergy & Intolerance Form
Page 2 of 3
_____hrs. _____days
iv. Please check the symptoms your child has experienced in the past:
Skin:
☐Hives
☐Itching
Mouth:
☐Itching
Abdominal:
☐Nausea
☐Swelling (lips,
tongue, mouth)
☐Cramps
Throat:
Lungs:
☐Itching
☐Tightness
☐Shortness of breath
Heart:
☐Weak pulse
☐Rash (tongue,
mouth)
☐Flushing
☐Vomiting
☐Diarrhea
☐Hoarseness
☐Repetitive
Cough
☐Cough
☐Swelling (face, arms,
hands, legs)
☐Wheezing
☐Loss of consciousness
e. Treatment
i. How have past reactions been treated?
ii. How effective was the student’s response to treatment?
iii. Was there an emergency room visit? ☐No ☐Yes, explain:
iv. Was the student admitted to the hospital? ☐No ☐Yes, explain:
v. What treatment or medication has your healthcare provider recommended for use in an
allergic reaction?
vi. Has your healthcare provider provided you with a prescription for medication? ☐No ☐Yes
vii. Have you used the treatment or medication? ☐No ☐Yes
viii. Please describe any side effects or problems your child had in using the suggested
treatment:
f. Self Care
i. Is your student able to monitor and prevent their own exposures?
ii. Does your student:
1. Know what foods to avoid
2. Ask about food ingredients
3. Read and understand food labels
4. Tell an adult immediately after an exposure
5. Wear a medical alert bracelet, necklace, or watchband
6. Tell peers and adults about the allergy
7. Firmly refuses a problem food
iii. Does your child know how to use emergency medication?
iv. Has your child ever administered their own emergency medication?
☐No
☐No
☐No
☐No
☐No
☐No
☐No
☐No
☐No
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
g. Family/Home
i. How do you feel that the whole family is coping with your student’s food allergy?
ii. Does your child carry epinephrine in the event of a reaction? ☐No ☐Yes
Updated 07/2015
Peregrine School Student Food Allergy & Intolerance Form
Page 3 of 3
iii. Has your child ever needed to administer that epinephrine? ☐No ☐Yes
iv. Do you feel that your child needs assistance in coping with his/her food allergy?
h. General Health
i. How is your child’s general health other than having a food allergy?
ii. Does your child have other health conditions?
iii. Hospitalizations?
iv. Does your child have a history of asthma? ☐No ☐Yes
If yes, does he/she have an Asthma Action Plan? ☐No ☐Yes
v. Please add anything else you would like the school to know about your child’s health:
i. Notes:
Parent/Guardian Signature:
Date:
Reviewed by Physician or R.N.:
Date:
Office Use Only
Chef Signature:
Updated 07/2015
Parent Meeting Date: