Pediatric Food Allergy Checklist

Patient Information

Child's Name:

Age:

Parent/Guardian Name:

Known Food Allergies

Milk
Egg
Peanut
Tree Nuts
Soy
Wheat
Fish
Shellfish
Sesame
Other:

Symptoms Observed

Hives / Rash
Swelling (face, lips, tongue)
Vomiting
Diarrhea
Coughing / Wheezing
Difficulty Breathing
Abdominal Pain
Other:

Reactions Timeline / Notes

Emergency Action Plan