ST. GABRIEL CHILD CARE FOOD ALLERGY FORM

(This form is to be completed for a diagnosed food allergy only, not a food intolerance.)

ALLERGY TO: _____________________________________

CHILD'S NAME ____________________________________

DATE OF BIRTH ___________________________________

ASTHMATIC (Circle) YES NO

My child may experience one or more of the following:

SYMPTOMS: (Please check)

____ Itching & swelling of the lips, tongue or mouth

____ Itching and/or sense of tightness in the throat, hoarseness, and hacking cough

____ Hives, itchy rash, and/or swelling about the face or extremities

____ Nausea, abdominal cramps, vomiting, and/or diarrhea

____ Shortness of breath, repetitive coughing, and/or wheezing

____ "Thready" pulse, "passing out"

ACTION:

If ingestion is suspected, give ___________________________________

medication/dose

and ______________________________________________immediately!

course of action

PHYSICIAN'S NAME___________________________ PHONE NUMBER________________

PHYSICIAN'S SIGNATURE ________________________________ DATE ______________

I give permission for the St. Gabriel Child Care staff to administer the above medication if necessary, and follow the course of action as directed by the above-named physician. I also understand that a daily permission note must be submitted (as per the SGCC handbook).

PARENT'S SIGNATURE ____________________________________ DATE______________

FOR CHILDREN WITH MULTIPLE FOOD ALLERGIES, USE ONE FORM FOR EACH FOOD.