ATS Allergies, Asthma and Anaphylaxis Form

Allergy, Asthma & Anaphylaxis Form

Participants First Name *

Participants Last Name *

Email Address *

Mobile Phone Number: *

Does the Participant have Asthma? *

YesNo

Is there an Asthma Management Plan in Place for the Participant?

If yes, please upload the Asthma Management Plan

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Does the Participant carry Medication for their Asthma?

Does the Participant know how to use their Medication?

Does the Participant have any Allergies? *

YesNo

Please list all Allergies

If answering yes, does the allergies require any Medications?

If yes, what is required to manage the Allergy?

Is the Participant Anaphylactic? *

Does the Participant Carry an Epipen or Appropriate Medication?

Does the Participant have any Food Intolerances?

If yes, what are they?

Any further information we should know about?