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STUDENT FOOD & BEVERAGE

INTOLERANCEAWARENESS FORM

Student Name / Teacher:
Date of Birth / // / History of serious allergy?
NO YES: see Allergy History &
Action form

Healthcare Provider, Parent or Guardian:This form is to be completedif the childhas known adverse reaction(s) to food or beveragesthat would substantially impair a student physically or mentally such that school participation may be affected or would impact the student’s ability to receive equal access and benefit from school programs and services. If the reaction is life threateningor a serious allergy, the STUDENT ALLERGY & ACTION PLANmust be completed. Please also list substitutes andexception–i.e. related substances that are known NOT to cause a reaction, so the school can provide an optimal plan; For example: Milk (lactose); Exception: Butter.

If treatment with medication is to be givenat school in the event of an exposure, page 2must be completed by a healthcare provider.

ADVERSE REACTION HISTORYdate form completed://20 weight: (lb.) or (Kg)

Specific Substance that causes reaction / Route(s) of exposurethat cause reaction / Type(s) of reaction(optional) / Substitute / Exceptions (that are known to be tolerated)**:
1. / oral ingestion
direct contact
other: / Bodily function affected(specify*):
Concentrating Seeing Hearing
Bending, standing, or walking
Caring for self
Communicating Sleeping
other:
2. / oral ingestion
direct contact
other: / Bodily function affected (specify*):
Concentrating Seeing Hearing
Bending, standing, or walking
Caring for self
Communicating Sleeping
other:
3. / oral ingestion
direct contact
other: / Bodily function affected (specify*):
Concentrating Seeing Hearing
Bending, standing, or walking
Caring for self
Communicating Sleeping
other:
4. / oral ingestion
direct contact
other: / Bodily function affected (specify*):
Concentrating Seeing Hearing
Bending, standing, or walking
Caring for self
Communicating Sleeping
other:

See attached addendum for additional Allergens/Substances.

*e.g. immune system, bowel, bladder, neurological, brain, respiratory, gastrointestinal, endocrine, or reproductive functions

Page 1 of 2

TREATMENTto be given at schoolPage 2 of 2

Substance / Symptoms / Treatment(s) Determined by Parent, Guardian or Healthcare Provider authorizing treatment; medication(s)must be specified in the next section
/
/
/
/
/

Healthcare Provider to complete:

MEDICATIONS authorized to be given at school (medication, dose, route must be specified)

Antihistamine: diphenhydramine (Benedryl®)liquid 12.5mg/tsp chewable 12.5mg/tab 25mg tablet
mg by mouth
cetirizine (Zyrtec®) liquid 5mg/tsp 10mg tablet
mg by mouth
(other):
Steroid (oral): drug: dose: by mouth
Others:

CONTACTS

PARENT/GUARDIANSPhone #1Phone #2

1)()- ()-

2)()- ()-

EMERGENCY CONTACTSPhone #1Phone #2

1)()- ()-

2)()- ()-

HEALTHCARE PROVIDER (name):______

_____()- ()-

Name of practice / Institution

Parent / Guardian Signature: date:

Physician/Provider Signature:date: