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Contact Sheet for Children in Daycares, Preschool, School, etc.


Information About Child


Name: ____________ ____________ _______________
Age: _______
Height: ___'___"
Weight: _____
Hair color: _______
Eye color: _______
Male Female
See picture at right
Child reacts to allergens (typically) in this way: _____________________________ ________________________________________________________________________________
Page added (child's reactions to food, etc.)


Allergies


Dairy Eggs Wheat Potato Peanuts Tree nuts Fish Shellfish Soy Other ________, ___________, _______________, ____________
Please note that these allergens can go by different names. For example, albumin can mean "eggs," "lactose" is milk. Alternate names for the above allergens include: ___________, ___________, ___________, ___________, ___________, ___________, ___________, ___________, ___________, ___________, ___________
Safe foods: ___________, ___________, ___________, ___________, ___________, ___________, ___________, ___________, ___________, ___________, ___________
Being touched/ exposed to an allergen (not just ingesting) can cause an allergic reaction in _______________.
Page added (safe foods included with child, additional allergens, etc.)


Contact Information


Father's name: __________________________
Work phone: _____-____________
Mother's name: __________________________
Work phone: _____-____________
Parents' home phone number: _____-___________
Parents' beeper, cell phone, or other way of contacting: __________________
Neighbor's home work number: ___-_____ (Name: ______________________)
Friend's home work number: ___-_____ (Name: ______________________)
Friend's home work number: ___-_____ (Name: ______________________)
Friend's home work number: ___-_____ (Name: ______________________)
Page added (who to contact)


Treatment if Exposed


Number, in order, of which to contact first.
Parent (numbers listed above)
Family doctor's number: ____-_____________
Pediatrician's number: ____-_____________
Hospital: ____-_____________
Allergist's number: ____-_____________
911
Use EpiPen
(Instructions {where stored, how to administer, etc.}: __________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ___________________)
Page added (treatment information)


This contact form was created by JB, NE, KL and MT and was supplied by Food Allergy Survivors Together (http://www.angelfire.com/mi/FAST). Parents can fill out this sheet with the help and input of their allergist, and append any needed information.

This website is for personal support information only. Nothing should be construed as medical advice.