Allergy/Health Questionnaire
If you have stated that your child has an allergy or health condition, we will need to know a little more info so that we know how best to care for your child.
Name Of Child *
Allergy/ Condition (s) Please name all if more than one *
Has this been diagnosed by a health care professional? *
A little more info into the background
How long has the child had this condition? *
Has your health care professional provided you with a Care plan? *
Do we have a copy of the health plan? *
Symptoms of condition *
Severity of condition *
very mild
Very severe
Any other information that we need to know?
Person Completing this form: *
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