MN DHS Child Allergy Information Form
Program Name
Child Name
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First Name
Middle Initial
Last Name
Child Date of Birth
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Month
-
Day
Year
Date
Describe the allergy. Allergies with similar symptoms can be listed together. Additional section(s) can be added for multiple allergies with different triggers, symptoms, and techniques.
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What triggers the allergy?
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All symptoms below may be experienced when exposed to an allergen. Please select any known symptoms the child may display:
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No history of symptoms or unknown
Mouth: Itching; tingling; swelling of lips, tongue or mouth ("mouth feels funny")
Skin: Hives; itchy rash; swelling of the face or extremities
Gut: Nausea; abdominal cramps; vomiting; diarrhea
Throat: Difficulty swallowing; hoarseness; hacking cough
Lungs: Shortness of breath; repetitive coughing; wheezing
Heart: Weak or fast pulse; low blood pressure; fainting; pale; blueness
Other
If needed, please list any additional information regarding symptoms:
What techniques will be used to avoid an allergic reaction?
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What procedures will be taken to respond to an allergic reaction for this child?
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Are medications required for response to an allergic reaction for this child?
Yes
No
Medication Name
*
Medication Dosage
*
Doctor Name
*
Doctor Phone Number
*
Please enter a valid phone number.
Signatures
I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
Parent/Guardian Name
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First Name
Last Name
Parent/Guardian Email
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example@example.com
Parent/Guardian Signature
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Date of Signature
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Month
-
Day
Year
Date
I have clicked "Preview PDF" and reviewed my form for accuracy
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Yes
No
Please verify that you are human
*
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