Senior Living Food Allergy Assessment
Resident Information
Resident Name
Date of Birth
Room Number
Assessment Date
Allergy Details
Known Food Allergies (list all)
Describe Reaction(s) to Allergens
Severity of Reactions
Mild
Moderate
Severe
Who Diagnosed the Allergy?
Date of Last Reaction
Management
Required Dietary Modifications
EpiPen/Medications Required (list)
Special Instructions for Staff
Assessment Completed By
Name
Role
Signature
Date