Allergy Questionnaire

Instructions for Parents & Carers

Please complete all of the required information.

Child's Personal Details

1. Child's First Name(s)(Do not enter initials, or shortened names, such as Jim for James or Liz for Elizabeth)

2. Child's Last Name

3. Child's Date of Birth

4. Parent's Email

5. Parent's Phone Number

5a. Child's Doctor's [GP] & Surgery Name

5b. Child's NHS Number

7. Please tell us what allergy[s] your child has

8. Please describe the allergic reaction that we can expect

10. When was your child's last allegic reaction?.

12. List prescribed medication, dose and frequency

14. What is the emergency medication [and does it travel with your child or is the medication kept at Nursery?]

15. Date Medication expires

17. If Yes please tell us the date

18. Please tell us if there is something else you think we should know about your Child's allergy, the reation they have or what to do if they have an allergic reation.

19. Please provide an image which shows us how your child's allergy reation looks e.g. a picture of the rash we can expect.

Upload File (jpg or png)

20. Parent Signature

21. Parent/Carer First Name

22. Parent/Carer Last Name

23. Enter today's date.