Childcare Service Intolerance Assessment Form
Use this form to share a child’s known intolerances, sensitivities, and care instructions so childcare staff can respond appropriately. Childcare Service Intolerance Assessment Form.
Child Information and Care Context
Child's Name
*
Age Group
*
Infant (0-12 months)
Toddler (1-2 years)
Preschool (3-5 years)
School-age (6-12 years)
Teen (13+ years)
Primary Caregiver Name
*
Childcare Setting / Program Type
*
Home daycare
Licensed childcare center
Preschool program
After-school program
Family childcare home
Other
Intolerance Assessment
Known Intolerances and Sensitivities
*
Rows
Present / None
Description
Typical Reaction / Response
Foods
1
Beverages
2
Materials
3
Scents
4
Environmental Triggers
5
Medications / Products
6
Overall Intolerance Severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Urgency / Care Priority
*
1
2
3
4
5
Care Instructions and Follow-up
Preferred handling instructions for the childcare team
*
Known emergency or warning signs to watch for
*
Best contact method for follow-up questions
*
Phone call
Text message
Email
Other
Submit Childcare Service Intolerance Assessment Form
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