1.Name of Student

2.Group

*3.Allergic to(Required.)

Mild

Strong

Life-Threatening

N/A

Gluten

Mild

Strong

Life-Threatening

N/A

Peanuts

Mild

Strong

Life-Threatening

N/A

Other nuts

Mild

Strong

Life-Threatening

N/A

Fish

Mild

Strong

Life-Threatening

N/A

Crustaceans

Mild

Strong

Life-Threatening

N/A

Molluscs

Mild

Strong

Life-Threatening

N/A

Sesame seeds

Mild

Strong

Life-Threatening

N/A

Eggs

Mild

Strong

Life-Threatening

N/A

Milk (cold, warm, in drinks)

Mild

Strong

Life-Threatening

N/A

Hard Cheese

Mild

Strong

Life-Threatening

N/A

Soft Cheese and Yoghurt

Mild

Strong

Life-Threatening

N/A

Any dairy products (any lactose)

Mild

Strong

Life-Threatening

N/A

Soy beans

Mild

Strong

Life-Threatening

N/A

Celery

Mild

Strong

Life-Threatening

N/A

Lupin

Mild

Strong

Life-Threatening

N/A

Mustard

Mild

Strong

Life-Threatening

N/A

sulphur dioxide and sulphites

Mild

Strong

Life-Threatening

N/A

Cats

Mild

Strong

Life-Threatening

N/A

Dogs

Mild

Strong

Life-Threatening

N/A

Horses

Mild

Strong

Life-Threatening

N/A

4.For Strong and Life-Threatening reactions, please list, in detail all medicine carried for use in the event of a reaction

5.Please list medical conditions

Hay Fever

Diabetis

Asthma

Siezures

Other (please specify)

6.For any medical condition, please give full details, an indication of severity and a full list of medicines