Food Allergy Questionnaire

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For your child's safety, any student that has a food allergy must have this questionnaire completed by a parent each year. If a student has an epinephrine auto-injector prescribed, we must have a Food Allergy Action Plan AND the epinephrine auto-injector on file in the nurse's office BEFORE the first day of school. Food Allergy Action Plans must be completed by your child's doctor before the beginning of the new school year and is valid for one year after the signature date.

1.	Student's name:*

2.	Grade:*

Trigger for reaction:*
Check all that apply.

Ingested

Inhaled

Skin contact

Other, please specify

5.	Date of last reaction:

6.	Please describe the incident leading to the diagnosis of a food allergy.* Please include age of onset, what food your child came in contact with, type of reaction, what you did for your child in response to the reaction (medication, epinephrine, etc.)

7.	Does your child recognize when he/she is having a reaction?*

8.	Is your child able to tell someone he/she is having a reaction?*

10.	Is your child asthmatic?*

11.	Does your child have eczema?*

12.	Does your child have an epinephrine auto-injector prescribed?*

13.	Has epinephrine ever been administered to your child as a result of an allergic reaction?*

14.

Name of your child's epinephrine auto-injector:
Check all that apply.

EpiPen

EpiPen Jr.

Auvi-Q

Auvi-Q Jr.

Other, please specify

15.

Where will your child keep his/her epinephrine auto-injector?
Check all that apply

Nurse's office (preferred)

After school care office (preferred if staying in ASC)

Classroom

Student's backpack

16.	Name of your child's allergist:*

17.	Date of last allergy testing:*

18.	If your student has a peanut or tree nut allergy. Can he/she consume foods with the label "manufactured in a plant that processes peanuts or tree nuts?"

19.	If your child has a peanut or tree nut allergy, do you prefer that your child sit at a peanut/tree nut free table in the cafeteria or in the classroom?

20.	If another student has brought a food item containing your student's allergen, can your child sit next to this student?

21.	Little Woodland, Pre-Kindergarten, & Junior Kindergarten ONLY: Because these students eat snack and lunch inside the classroom, this question will pertain to food items brought by other student for their own consumption. This does NOT include shared snacks. Does the severity of your child's allergic reaction necessitate certain food items not be in the classroom? (IF YES, a Food Allergy Action Plan AND a letter from your child's doctor indicating this exclusion will be required.)

22.	Do you feel that your child has a good understanding about his/her allergy and which foods they should avoid?*

23.	Any other information you would like for the nurses to be aware of?

AGREEMENT: By signing this Electronic Signature Acknowledgement Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

By signing below, I accept the conditions of this agreement.

24.	Parent signature:

25.	Today's date:
	mm/dd/yyyy