Student’s Name（ChineseName）
学生姓名（中文全名）
Does your child have a diagnosis of anallergy from a healthcare provider?
您的孩子是否被医疗机构诊断为过敏？
History and Current Status
过敏史及现状
What is your child allergic to?
您的孩子对什么过敏？
Peanut花生
Eggs鸡蛋
Milk 牛奶
Latex 乳胶
Soy大豆
Fish/Shellfish 鱼／贝类
Chemicals 化学物质
Vapors 蒸汽
Tree Nuts 坚果
Insect Stings 蚊虫叮咬
Other其他
Age of student when allergy was first discovered
第一次发现过敏是几岁？
How many times has student had areaction?
学生发生几次过敏反应？
Never从不
Once 一次
More than once超过一次
Explain past reactions symptoms:
描述一下过去的反应症状:
Are the food allergy symptoms
是与食物过敏症状:
Trigger and Symptoms 发作及症状
What are the early signs andsymptoms of your child’s allergic reaction?
您的孩子的过敏早期症状表现是什么？
Please check the symptoms that your child hasexperienced in the past:
请确认您的孩子在过去有过哪些症状？
SKIN皮肤:
HIVES寻麻疹
ITCHING瘙痒
RASH 皮疹
FLUSHING 脸红
SWELLING肿胀
ABDOMINAL腹部
NAUSEA恶心
CRAMPS痉挛
VOMITING呕吐
DIARRHEA 腹泻
THROAT喉咙
ITCHING瘙痒
TIGHTNESS紧
COUGH咳嗽
HOARSENESS嘶哑
LUNGS肺部
SHORTNESS OF BREATH呼吸急促
REPETITIVE COUGH 持续咳嗽
HEART心脏
WEAK PULSE弱脉
LOSS OF CONSIOUSNESS失去意识
Has your child ever required an EpiPen?
您的孩子需要注射肾上腺素吗？
How effective was your student’s response to treatment?
您的孩子对于接受治疗的效果是怎样的？
For student’s with an Egg Allergy 学生对于鸡蛋过敏
May your child eat eggs in baked goods?
您的孩子可以吃内含鸡蛋成份的烘培类食物吗？
For Student’s with a Milk Allergy 学生对于牛奶过敏
May your child eat any products containing milk?
您的孩子对于任何奶制品都过敏吗？
Circle the foods with milk your child is allowed to eat.
圈出您的孩子可以吃的含有部分奶制品的食物。
PIZZA 披萨
CHEESE 芝士
Yogurt Food with milk as an ingredient含有牛奶的酸奶食物
其他含奶食品