Allergy Self Management Check List Template
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1Allergy Self Management Check List
The purpose of this checklist is to obtain information about your child’s understanding and needs related to their
food allergy. Please take a few minutes to answer the following questions.
Student Name:_________________________________
2015-2016 School Year
Grade:_________
Teacher:___________________________
Please attach
picture
Allergic to:____________________________________________________________
Ingestion
Contact
Inhalation
1. The student is always able to visually recognize the allergen in all of its forms (ex.
Peanut butter) or part of another food (ex. Peanut butter cookies).
Yes
No
2. The student is able to read food labels for the offending allergen.
Yes
No
3. The student is always able to recognize signs of allergic reaction.
Yes
No
Signs/ Symptoms student experienced with reaction:
___________________________________________________
4. The student is always able to verbally communicate body discomfort associated with
allergic reaction.
Yes
No
5. The student knows to wash his/ her hands well with soap and water before eating.
Yes
No
6. The student knows only to eat foods brought from home.
Yes
No
7. The student always knows not to trade food with classmates and adults.
Yes
No
8. The student always knows the steps to take if having an allergic reaction.
Yes
No
9. The student always understands how safe foods may become cross-contaminated with
an allergen.
Yes
No
10. The student knows if he/she needs to take medication in the event of accidental
allergen ingestion.
Yes
No
Medication Prescribed_______________________________________________
11. Does you child need to sit at the nut free table in the cafeteria
Yes
No
12. Does your child need to sit at the nut free computer in the computer lab
Yes
No
Parent Signature:__________________________
Date:__________________________________
This form is modified from The School Food and Allergy Program
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