STING/FOOD ALLERGY HEALTH HISTORY FORM and FOOD QUESTIONNARIE

Student Name: Date of Birth:

Primary Healthcare Provider: Phone:

Allergist: Phone:

Does your child have a diagnosis of stinging insect or food allergy from a healthcare provider?

NoYes

History and Current Status:

  1. What is your child allergic to?

Peanuts / Milk / Soy / Fish/Shellfish
Eggs / Latex / Insect Stings / Tree Nuts (Walnuts, Pecans, etc.)

Other:

  1. Age of child when allergy first discovered:
  2. How many times has student had a reaction? Never Once More than once
Describe:
  1. When was the last reaction?

Symptoms

  1. What are the signs and symptoms of your child’s allergic reaction?

Hives / Rash / Itching / Vomiting
Swelling / Hard to Breath / Wheezing
Other: Please Describe
  1. How does your child communicate their symptoms? What might your child say?

Treatment

  1. How have past reactions been treated?
  2. Was there an emergency room visit? Describe:
  3. What treatment or medication has your healthcare provider prescribed and/or recommended for use for an allergic reaction?

Self-Care:
Does your child / No / Yes / Not Applicable
  • Know what foods to avoid?

  • Ask about food ingredients?

  • Read and understand food labels?

  • Tell an adult immediately after an exposure?

  • Wear a medical alert bracelet, necklace or watchband?

  • Tell peers and adults about the food allergy?

  • Firmly refuse a problem food?

  • Know how to use emergency medications?

  • Carry epinephrine auto-injector?

  • Ever administered their own emergency medication?

  • Does your child worry a lot about accidental exposure to food allergens?

General Health
  1. Does your child have other health conditions?
  2. Hospitalizations?
  3. Does your child have a history of asthma?
  4. Anything else you would like school to know about your child’s health?
Food Questions
  1. What type of snack foods do you recommend for your child in elementary and middle school classroom? (Classroom teachers are asked to minimize allergens in the classrooms when at all possible.)
Only snacks from home
Only snacks from list provided by parent
My child is old enough to make their own decisions on classroom snack foods
Other:
  1. Will your child participate in the MMSD Food Service Program for breakfast or lunch?
Yes
No

Completed by parent/guardian (name): Date:

Reviewed by R.N. (name): Date:

August 2017