Bee or Insect Allergy Form 2022-2023 Step 1 of 4 25% Bee or Insect Allergy Form 2022-2023Child's Name:* First Last Birthday:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120002022-2023 Grade:*3 Years OldJunior KindergartenKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th GradeParent/Guardian Name* First Last Parent/Guardian Cell Phone*Parent/Guardian Home Phone*Parent/Guardian Work Phone*Second Parent/Guardian Name First Last Second Parent/Guardian Cell PhoneSecond Parent/Guardian Home PhoneSecond Parent/Guardian Work PhoneEmail address to send confirmation of form completion* Do you think your student’s bee or insect allergy may be life-threatening? (If yes, please contact the main office as soon as possible).* Yes No Did your student’s health care provider inform you the bee or insect allergy may be life-threatening? (If yes, please contact the main office as soon as possible).* Yes No History and Current StatusWhat type of stinging bee or insect has your student reacted to?* How many times has your child had a reaction?* Never Once More than once If more than once, please explain:* When was the last reaction?* Are the reactions:* Staying the same Getting worse Getting better Has your student ever needed treatment at a clinic or the hospital for an allergic reaction?* Yes No If yes, please describe:* Has your student ever received or used an Epi-pen® or other injection as treatment?* Yes No If yes, please describe:* Triggers and SymptomsWhat are the signs and symptoms of your student’s allergic reaction? (Be specific. Please include things the student might say.)*How quickly do the signs and symptoms appear after the sting?* Seconds Minutes Hours Days TreatmentDoes your student understand how to avoid getting a bee sting or insect bite?* Yes No What do you do at home if there is a reaction to a bee sting or insect bite* What treatment or medication has your health care provider recommended for an allergic reaction?* Have you used the treatment or medication?* Yes No Does your student know how to use the treatment or medication?* Yes No Please describe any side effects or problems your student had in using the suggested treatment or medication.* Other Forms and ConsentIf medication is to be available at school, have you submitted a Permission for Prescription Medication to school?* N/A Yes No, I need to acquire the form, have it completed by a licensed health professional and return it to school. If medication is needed at school, have you brought the medication/treatment supplies (in original packaging) to school?* N/A Yes No, I need to bring the medication/treatment to school and submit a Permission for Prescription Medication form to school. What do you want the school to do in case of a bee sting or insect bite?*I give consent to share, with the classroom, that my child has a bee sting or insect bite allergy.* Yes No Name of Licensed Health Professional (LHP) treating bee/insect allergy* First Last LHP Phone Number*Parent/Guardian Initials* By initialing here, you are agreeing that all information on this form is accurate to your knowledge.Second Parent/Guardian Initials By initialing here, you are agreeing that all information on this form is accurate to your knowledge.EmailThis field is for validation purposes and should be left unchanged. Δ