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Overview
Complete
Food Allergy Form
Saint Scholastic High School / June Butterfield / 28 Feb 2020
Inspection score
10.71%
Failed items
0
Created actions
0
Facility Name
Saint Scholastic High School
Student Name
June Butterfield
Prepared by
Mallory Davis
Date

28th Feb, 2020

4:00 PM +08

Food Allergy Form
10.71%
Take or Attach Picture of Student
Photos
Age
7
Birth Date

12th Jun, 2013

Student's Parent or Guardian Name
Grace Butterfield
Relationship to Student
Mother
Parent's Contact No. (Work)
3054208222
Parent's Contact No. (Home)
3057508321
Food Allergy / Intolerances
7.41%
Food Allergy
Peanuts
Intolerances
Others
Please specify
No intolerances
Other special diet needs or restrictions (i.e., Diabetes, IBS, other)
Avoids food with blood or rarely cooked meat such as blood sausage and blood soup
Dietary Needs Questionnaire
100%
Please answer the following questions to better help us with your needs:
What are the preferred food substitutions, if any? (e.g., soy butter for peanut butter, gluten-free bread, soy milk, etc):
Any food without any ingredient of peanuts should be fine
What types of contact will cause a reaction?
Actual ingestion of food
Please explain
Ingesting food with the slightest trace of peanuts will trigger allergic reactions, making it hard for her to breathe and swell
Does the Student understand the food allergy and what needs to be done to manage it?
Yes
Completion
By signing this I am certifying I understand the disclaimers contained in this form and I verify the information provided is true and correct.
Parent/Guardian Signature
Grace Butterfield
28th Feb, 2020 4:10 PM +08
Media summary
1 Media