Food Allergy Assessment Form 2022-2023 Step 1 of 4 25% Food Allergy Assessment 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 food 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 food allergy may be life-threatening? (If yes, please contact the main office as soon as possible).* Yes No History and Current StatusCheck the foods that have caused an allergic reaction:* Peanuts Peanut Butter or Nut Butter Peanut Oil or Nut Oil Fish/Shellfish Soy Products Tree Nuts (Walnuts, Almonds, Pecans, etc.) Eggs Milk Wheat Other Food Allergies: 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 food allergy reactions:* Staying the same Getting worse Getting better Triggers and SymptomsWhat has to happen for your student to react to the problem food/s? Check all that apply.* Eating foods Touching foods Smelling/inhaling foods Other If other, please explain:* What 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 exposure to the food/s?* Seconds Minutes Hours Days TreatmentHas your child ever needed treatment at a clinic or the hospital for an allergic reaction?* Yes No If yes, please explain:* Does your student understand how to avoid foods that cause allergic reactions?* Yes No What treatment or medication has your health care provider recommended for use in 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 you intend for your child to eat school provided meals, have you completed and submitted a Medical Statement for Student Requiring Special Meals form for 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 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 us to do at school to help your student avoid problem foods?*I give consent to share, with the classroom, that my child has a life-threatening food allergy.* Yes No Name of Licensed Health Professional (LHP) treating Food 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.PhoneThis field is for validation purposes and should be left unchanged. Δ