Name (DOB: MM/DD/YYYY)

Teacher Name’s (insert Grade #) Grade Class

Life-threatening food allergies to ALL products containing: milk/dairy, beef, gelatin, eggs, peanuts, peas, beans, all nuts, mustard, sunflower, sesame Picture
Asthmatic (inhaler is with Nurse); Also allergic to dogs, cats, various pollens
Carries (2) emergency epinephrine injectors (Auvi-Q) in a carrier around his waist*.

Phrases (Name) may use to describe symptoms of an allergic reaction:

SYMPTOMS OF A FOOD ALLERGY REACTION*:
Any single symptom or any combination of symptoms*
Vomiting (sometimes without warning)
Nausea
Hives, itchy skin, skin redness
Itchy/runny nose, sneezing
Itchy mouth or throat
Repetitive coughing
“I feel something on my tongue”
“My throat/mouth/tongue feels funny”
Common for ( ) “My throat feels yucky”(can mean nausea or throat swelling)
“My breathing feels yucky” (can mean nausea or wheezing)
Common for ( ) “This food is too spicy/hot”
(Name) sometimes fails to speak up when he doesn’t feel well, especially with nausea or
Common for ( )
stomach upset. He may look worried, pale, become very quiet, or drink large amounts of
Common for ( ) water. He may also spend a long time in the bathroom and be embarrassed to tell anyone
that he feels ill.
Common for ( ) If (Name) ever spits out a food when eating, he should be sent to the nurse to be observed,
Common for ( ) as this is not unusual during an allergic reaction.

Wheezing or shortness of breath Common for ( ) Causes of allergic reactions for (Name):
Tight throat, hoarse voice, trouble breathing Common for ( )  “Ingestion” of an allergen can happen through brief contact with any mucous
or swallowing membrane: saliva, the nose, and/or eyes. (Even if a food is spit out and not swallowed.)
 (Name)’s food/drink is “contaminated” through contact with other foods/drinks.
Excessive drooling Common for ( )  Other students cough/sneeze/vomit/spit near/on (Name) or his food. (Research has
shown that allergenic food proteins remain in the saliva for 9 hours.)
Swelling of the face, tongue, and/or lips Common for ( )  Contact with (Name)’s skin (touching foods or surfaces that contain foods, even food
Stomach cramping Common for ( ) residues not seen by the eye).
 Inhaling dusty nut proteins (e.g. trail mix, nuts), dusty cheese or dairy foods (e.g.
Anxiety, doom, confusion Common for ( ) Goldfish, Cheetos, Doritos), and cooked or steaming dairy (hot chocolate or coffee with
milk, hot pizza).
Pale, blue, faint, weak pulse, dizzy Has Occurred
Diarrhea Possible Recommendations (Please also see Section 504 Accommodation Plan)
• (Name) may only consume food, drinks, treats provided by his parents.
• Should be discouraged from touching his face, especially his eyes/nose/mouth.
Please consult with the Nurse immediately for any and all
• Other foods/drinks cannot make contact with or touch (Name)’s foods/drinks (e.g.
complaints or unusual behaviors by (name)*. What may seem like
shared containers, utensils, close proximity).
nothing or a simple virus can actually be the start of a serious, and
• (Name) may not drink from the water fountain or share utensils, napkins w/others.
urgent allergic reaction. • All must wash/wet wipe hands before handling (Name)’s food/drink.
Every second counts. • Hand sanitizer does NOT remove food proteins or allergens. Hands must be washed
with soap and water, or wiped thoroughly with commercial hand wipes.
*Refer to (Name’s) Emergency Action Plan for • Milk proteins and nuts can lurk in hand soaps, lotions, personal care products, art
supplies, and potting soils. All items should be discussed with (Name)’s parents first.
details. • If (Name)’s clothes become soiled with others’ food or drink, he must be sent to the
Emergency contact: (phone #) nurse immediately to change.