FOOD ALLERGY QUESTIONNAIRE 食物过敏调查问卷-调查问卷模板-问卷网

Student’s Name（ChineseName）

学生姓名（中文全名）

____________

Date of Birth

出生年月

____________

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？

是 Yes

否 No

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（没有填“无”）:

____________

Are the food allergy symptoms

是与食物过敏症状:

Same相同

Better好些

Worse更糟

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

MOUTH口腔

ITCHING瘙痒

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

Treatment 治疗

Has your child ever required an EpiPen?

您的孩子需要注射肾上腺素吗？

是 Yes

否 No

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？

是 Yes

否 No

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？

是 Yes

否 No

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

家长姓名填写

____________

联系电话

____________

FOOD ALLERGY QUESTIONNAIRE 食物过敏调查问卷

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