NURSE'S OFFICE ALLERGY INFORMATION SHEET

PHOTO ID
NURSE’S OFFICE
ALLERGY INFORMATION SHEET
Dear Parent/Guardian,
Please complete the information below and return it to us as soon as possible, so that we may provide the best
care for your child. Please notify the school nurse if any changes occur during the year.
Name of Child________________________________________________ Grade/Class______________
Date of Birth_______________________________ Today’s date_____________________________
GENERAL HISTORY
! Please state your child’s allergy and allergic reaction symptoms
#1 ALLERGY_______________________________________
SYMPTOMS___________________________________________________________________________________________
______________________________________________________________________________________________________
#2 ALLERGY________________________________________
SYMPTOMS___________________________________________________________________________________________
______________________________________________________________________________________________________
! List medication child takes at home for allergy:
Name/Dose/Frequency:
1_____________________________________________________________________________________________________
2_____________________________________________________________________________________________________
Side effect of medication (if any) __________________________________________________________________________
! Following an allergy attack have you ever had to give your child: ? Benadryl
? Epi Pen ( epinephrine)
? other medication____________________________
! Number of times your child has been taken to an emergency facility for an acute allergy attack in the past 12 months_____
! Additional information/instructions_____________________________________________________________________
Signature of Parent/Guardian______________________________________________ Date____________________________

FOOD ALLERGY
Student:
Grade:
School Contact:
DOB:
Asthmatic: U Yes E No (increased dsk for severe reaction)
Mother MHome #:
Father: FHome #:
Allergen(s):
MWork #:
FWork #:
MCell #:
FCell #:
Emergency Contact: Relationship: Phone:
SYMPTOMS OF AN ALLLERGIC REACTION MAY INCLUDE AAIY/ALL OF THESE:
. MOUTH Itching & swelling of lips, tongue or mouth, mouth "fecls hot"
. THROAT Itching, tightness in throag hoarseness, cough
' SKIN
Hives, itchy rash, swelling of face and extrcmitics
. STOMACH Nausea, abdominal crarnps, vomiting, diarrhea
. LUNG Shortness of bteath, tepetitive cough, wheezing
. HEART "'lhready pylse", "passing out"
The severity ofsymptoms can change quickly -
it is important that treatrrent is give inmediately.
STAFF MEMBERS INSTRUCTED:
[] Administration
O Classroom Teacher(s)
fl Support Staff
o
o
Special Area'I'eacher(s)
Transportation Staff
Student
Photo
TREATMENT:
Rinse contact area u.ith watet if appropriate
Treatment should be initiatcd fl with symptoms E without waiting for symptoms
Bcnadryl ordcrcd: D Yes D No Givc - Benadryl per provider's ordcrs
Call school nume. Call pxentf gvardian i[ ofF school gtounds.
Epincphrine ordcrcd: D Ycs D No Spccial instrucdons:
IF INGESTION OR SUSPECTED INGESTION OF ALLERGEN OCCURS, SYMPTOMS ARE PRESENT
AND EPINEPHRINE IS ORDERED, GTVE EPINEPHRINE IMMEDIATELY AND CALL 911.
Prefered IIospital if tansported:
trpinephrine provides a 20 minute response window. After epinephrine, a student may feel