Allergy and Anaphylaxis Health Update Form
Personal Information
Full Name
Date of Birth
Grade/Class
Parent/Guardian Name
Phone Number
Email Address
Medical Practitioner Details
Doctor's Name
Doctor's Phone
Allergy Details
List all Allergies (e.g. food, insect, medication, environmental)
Describe the allergic reaction(s) experienced
Has the individual ever experienced anaphylaxis?
Yes
No
Date of last allergic reaction
Treatment & Management
Current Medications (e.g. EpiPen, Antihistamines)
Is an EpiPen prescribed?
Yes
No
Attach/analyze Individual Anaphylaxis Action Plan
Emergency Contact Details
Emergency Contact Name
Emergency Contact Phone
Relationship to Individual
Additional Information
Any specific instructions or other relevant health information