Adventure Lifesigns

Anaphylaxis Questionnaire

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Explorer's Details

Name:

School:

Expedition code:

Destination & Year:

Date of birth:

Declaration

I confirm that my child suffers from an anaphylactic reaction and wish to declare the following information

When was your child's last attack?

What triggered their last reaction?

What medication did they use to treat the last reaction?

What else, if anything, has previously caused/is likely to trigger a reaction?

Is their allergy triggered by:

Airbourne Particles

Contact

Ingestion

What preventative measures do they take?

Does your child carry an adrenaline auto-injector?

If ‘YES’, please give details, including the make/brand of the auto-injector:

Do they use any other medication for this condition?

If ‘YES' please give details:

Does your child have a management plan?

If 'YES' please upload a copy below. If your child does not currently have a management action plan, you will be asked to complete one prior to departure.

Upload file

Have they ever required hospital admission because of a reaction?

If 'Yes' please give details included dates:

Does your child suffer from any other health issues e.g. Asthma?

If 'Yes' please give details:

Have you sought advice from your doctor or hospital prior to completing this health declaration?

If 'Yes', what did the doctor / specialist advise?

Do you have any additional comments or declarations to make regarding your child's health, allergies or anaphylaxis?

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Important:

I fully understand that expeditions have an element of the unknown insofar as there is a language barrier and when eating in restaurants food will be pre-prepared. Additionally, I confirm I have been advised that if I am unsure about my child's suitability to take part in this expedition I should consult their Doctor or Anaphylaxis Clinic, before signing this certificate and declaration. Should my child's anaphylactic reactions change, requiring any amendment to the above questionnaire, before arriving for activities, I undertake to advise the person in charge immediately.

Parent/ Guardian signature:

Student signature:

Date:

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Declaration

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I confirm that the information provided by me is to the best of my knowledge true and correct.

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Adventure Lifesigns reserves the right to withdraw participants from the expedition if any information is found to be false.