Food Allergy Survivors Together
( http://www.angelfire.com/mi/FAST/)
Contact Sheet
for Children in Daycare, Preschool, School, or with Caregivers
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
Who to contact and in which order:
Parent (numbers listed above)
Family doctor ________________________________________ phone: ____-_____________
Hospital: ____________________________________________ phone: ____-_____________
Allergist : ____________________________________________phone: ____-_____________
911
Use EpiPen
(Instructions {when to use, where stored, how to administer, etc.}: __________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________
Page added (treatment information)This contact form was reprinted in the Food Allergy Field Guide, by Theresa Willingham (Savory Palate, Inc., 2000) by permission of Food Allergy Survivors Together (FAST), http://www.angelfire.com/mi/FAST,and created by JB, NE, KL and MT. Parents can fill out this sheet with the help and input of their allergist, and append any needed information.