Food Allergy Action Plan Form

Food Allergy Action Plan Form — Form Fields

This healthcare template includes 6 fields. Documents a patient's known food allergies and emergency response instructions for caregivers and school or workplace staff. Supports safe management of severe allergic reactions. Free to customize and use on ZenBuild.

• Patient / Student Name (text, required)
• Date of Birth (text, required)
• Known food allergens (checkboxes, required) — options: Peanuts, Tree nuts, Milk / Dairy, Eggs, Wheat / Gluten, Soy, Fish / Shellfish, Other
• Severity of allergic reactions (dropdown selection, required) — options: Mild (hives, itching), Moderate (vomiting, swelling), Severe / Anaphylaxis
• Does the patient carry an epinephrine auto-injector (EpiPen)? (multiple choice, required) — options: Yes, No, Prescribed but not currently carrying
• Emergency contact information and response instructions (long text, required)