Food Allergy Form

Food allergy forms contain the following:

• Participant information (e.g., participant and guardian name, contact number, etc.)
• Food allergy (e.g., dairy, soy, eggs, peanuts, fish, etc.)
• Food intolerance (e.g., gluten, lactose, fructose, histamines, etc.)
• Dietary needs (e.g., soy butter, gluten free breads, soy milk, etc.)

What is a Food Allergy Action Plan Form?

A food allergy action plan form or a food allergy and anaphylaxis emergency care plan outlines the recommended treatment instructions in case of an allergic reaction. This form is designed to help non-medically trained personnel to perform the appropriate treatment for severe allergic reactions like anaphylaxis in the event of an emergency.

Elements of a Food Allergy Action Plan Form

There is no cure for food allergies and intolerances, but you can avoid life-threatening situations caused by allergic reactions by fostering a proactive approach with the use of a food allergy action plan form.

Below are 5 elements that should be found in a food allergy action plan form:

1. Criteria
   A symptoms criteria will help the person responsible for treatment to identify the type of allergic reaction, whether it is: mild, moderate, or severe. This will determine which treatment instructions will be most appropriate to effectively manage the allergic reaction.
2. Medications and dosages
   Create a fillable section to identify brand and dosage of epinephrine and antihistamine given to the participant with allergic reactions.
3. Treatment instructions
   A good food allergy action plan form should include instructions on how to recognize anaphylaxis and demonstrate how to give a life saving epinephrine.
4. Required signatures
   The allergy action plan form should be signed by a physician and the parent/guardian if the participant is a minor, otherwise the patient will sign it to verify the information provided in the form.
5. Emergency contacts
   Emergency contacts are comprised of (but is not limited to) a rescue squad, doctor, parent/guardian or any other relative. After treating the participant, the emergency contacts provided in the form will be contacted.

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