Sample Doctor/allergist Letter Template printable pdf download

Sample Doctor/Allergist Letter

Parents should also have the child’s allergist write a letter stating the diagnosis. It is particularly helpful to have

the child’s doctor address the major life activity(ies) limited by the child’s food allergies and any other concerns

unique to the child. Below is a sample letter for an allergist. Items in brackets should be customized to your

child:

To Whom It May Concern:

[Child’s name] has severe, potentially life-threatening food allergies to [list food allergies]. These allergies

substantially limit several major life activities, including [eating, breathing, and digestive functions].

With a food allergy, a reaction results from exposure to a food's protein. This protein may be present in all

forms of the allergenic food and products containing that food (even in trace amounts). For example, as

[Child’s name] is allergic to [allergen], [allergen] in all forms and all products that contain [allergen] MUST

be avoided. I am attaching a sheet with information on other sources of [child’s name]’s allergens, including

non-food sources, and other helpful information to this letter.*

Also, as [Child’s name] must strictly avoid his/her allergens, this includes foods that may be cross-

contaminated with an allergen. These foods may be labeled with a warning such as "may contain..," "processed

on shared equipment with... ," or "manufactured in a facility that also processes... ," but these warnings are

voluntary. The Food Allergen Labeling and Consumer Protection Act (FALCPA) does not require

manufacturers to warn for possible cross-contamination. Ultimately, in many cases the only way to know if an

item is safe may be to call the manufacturer.

EXAMPLE OF A UNIQUE CIRCUMSTANCE THAT MIGHT NEED TO BE ADDRESSED FOR AN

EXTREMELY FOOD-SENSTIVE CHILD: Ingesting even a trace amount of any of [Child’s name]’s allergens

has the potential to cause like-threatening anaphylaxis. He/she is at risk even by transferring protein from

his/her hands (after touching an allergy-contaminated surface or item) to his/her mouth or other mucous

membrane. Additionally, [Child’s name] is contact reactive to all of his/her allergens. School supplies and craft

items can be an unexpected source of allergens. Please refer to the attached list of possible sources of allergens

for more information.*

Should you have any additional questions or need any additional verification, please let me know.

* List food allergies and other sources of allergens, including non-food sources. It may be helpful to visit

FAACT’s

Food Allergens

page and print the PDF page about each allergen to which the child is allergic.

Sample Doctor/allergist Letter Template