BVS Allergy Questionnaire
If your child has allergies, please complete this form with the assistance of your child's doctor.
Prefer not to say
My child has allergies to:
Dairy (not baked)
Any allergies not listed in the list above:
Describe your child's allergic reaction
mild: runny nose, itchy/red eyes, frequent sneezing
moderate: hives, intense itching, scratchiness to throat
severe: difficulty breathing, wheezing, throat tightness, lip swelling, high risk for anaphylactic shock
triggers asthma attack
Comments about allergic reaction:
Has your child every had an anaphylactic reaction?
If yes, please describe when/how many times/trigger:
Does your child take medication for this allergy? If yes, please list medication. (Name of medication, frequency, used at home or school or both, etc.)
Is there a need to keep medication at school for this allergy? (If yes, please fill out an authorization form at school.)
If yes, where would you like your child's medication to be kept?
in child's backpack
Does your child have an EpiPen (self administered injection of epinephrine)?
If yes, where would you like your child's EpiPen to be kept?
Are there any limitations/restrictions of physical activities at school due to allergies? If yes, please specify.
A copy of your responses will be emailed to the address you provided.
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