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Child Health & Allergy Information

Please complete the following to help us care for your child safely and effectively.

General Health

Does your child have any known medical conditions?
No
Yes
2. Is your child currently under a physician's care for any condition?
No
Yes
3. Has your child had any recent surgeries or hospitalizations?
No
Yes
4. Does your child require any daily medications?
No
Yes

Allergies

5. Does your child have any food allergies?
No
Yes
6. Does your child have any environmental allergies (e.g. pollen, dust, mold, animal dander)?
No
Yes
7. Does your child have any medication allergies?
No
Yes
8. What type of reaction does your child have when exposed to these allergens? (e.g. rash, hives, difficulty breathing, anaphylaxis)
No
Yes
9. Has your child ever required the use of an EpiPen or other emergency medication for allergies?
No
Yes
10. Does your child carry an EpiPen or inhaler with them?
No
Yes
11. Are there any specific procedures or emergency action plans we should follow in the event of an allergic reaction?
No
Yes

Dietary Restrictions (Related to Allergies or Medical Conditions)

12. Are there foods your child must completely avoid?
No
Yes
13. Are there any food substitutions or special preparations required for your child?
No
Yes

Other Emergency Concerns

14. Has your child ever experienced an asthma attack or breathing difficulty?
No
Yes
15. Is there any other health information that would help us care for your child safely and effectively?
No
Yes
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