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HCA Food Allergy Survey
Please take the time to complete the attached food allergy survey. Completion of this survey will allow us to communicate your student's needs with teachers and dietary. Please let us know if you have any questions.
Email address *
Date:
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YYYY
Student Name:
Your answer
Form Completed by:
Your answer
What is your child allergic to?
Your answer
What type of a reaction did your child experience?
Your answer
How was the reaction treated?
Your answer
When was their last reaction? Approximate date or age:
Your answer
Does your child have emergency medication for their allergy? If yes, please list the name and dosage of the medication(s).
Your answer
Does your child carry emergency medication with them?
Seating:
Does your child need to sit at a "Nut-Free" table?
Your answer
Considering the severity of your child's food allergy, what is a safe distance from the said allergen during a lunch/snack period? For example, "My student may or may not sit next to another student consuming the allergen."
Your answer
Parent Responsibilities
Provide the nurse with medical confirmation and medication orders from your physician. Keep the nurse in your child’s school updated on your child’s allergy status.

If needed, provide the school with an emergency pack containing up-to-date Epi-Pens and oral antihistamine.

Provide the school with a way to reach you (phone numbers/email).

Provide the school with a list of foods and ingredients to avoid.

Review the lunch menu and know what is safe for your child. Contact the Food Service Department or the nurse as necessary.

Consider assisting with classroom functions and activities when possible.

Be aware of classroom activities and contact the teacher if you have questions or concerns.

Consider providing your child with a medic-alert bracelet/necklace.

Provide a supply of “safe” snacks to the teacher so your student may be included in all activities involving food.

A copy of your responses will be emailed to the address you provided.
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