Health Office Questionaire
Date:________________       Name:____________________________      Grade_________________


1.  Is student allergic to any food products?__________ If yes, pleaselist (shellfish, peanuts, eggs, dairy,       tree fruits...) and explain date of initial exposure and type of reaction

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2.  Is student allergic to bee stings? _________ If yes, please describe date of exposure and type of
    reaction ( hives, difficulty breathing, swelling at site)

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Does student have epipen/Benadryl__________

Has student ever received epipen/Benadryl _____

Has student had allergy testing __________    RAST or skin testing _______

Any emergency room visits related to exposure ________________________________________

3.  Is student allergic to any medications __________________________________________________

4.  Is student allergic to latex ____________________________________________________________

5.  Any other allergies you are aware of ___________________________________________________

6.  Does student take any medications (include 'over the counter") ____________________________

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Please list ANY other medical/psycho-social needs of which the Health Office should be aware:

(Asthma, Diabetes, ADD/ADHD, GI disorders, bleeding disorders, seizure, migraines, special dietary needs, etc.)

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Thank you,

Health Office Staff