Food Allergy Action Plan Template
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1
2Food Allergy Action Plan
Student’s
Place
Name:__________________________________D.O.B:_____________Teacher:________________________
Child’s
:______________________________________________________________
ALLERGY TO
Picture
Here
Asthmatic Yes*
No
*Higher risk for severe reaction
STEP 1: TREATMENT
Symptoms:
Give Checked Medication**:
**(To be determined by physician authorizing treatment)
Epinephrine
Antihistamine
If a food allergen has been ingested, but no symptoms:
Epinephrine
Antihistamine
Mouth
Itching, tingling, or swelling of lips, tongue, mouth
Epinephrine
Antihistamine
Skin
Hives, itchy rash, swelling of the face or extremities
Epinephrine
Antihistamine
Gut
Nausea, abdominal cramps, vomiting, diarrhea
Epinephrine
Antihistamine
Throat†
Tightening of throat, hoarseness, hacking cough
Epinephrine
Antihistamine
Lung†
Shortness of breath, repetitive coughing, wheezing
Epinephrine
Antihistamine
Heart†
Thready pulse, low blood pressure, fainting, pale, blueness
Epinephrine
Antihistamine
Other†
________________________________________________
Epinephrine
Antihistamine
If reaction is progressing (several of the above areas affected), give
†
The severity of symptoms can quickly change.
Potentially life-threatening.
DOSAGE
Epinephrine: inject intramuscularly (circle one) EpiPen® EpiPen® Jr. Twinject™ 0.3 mg Twinject™ 0.15 mg
(see reverse side for instructions)
Antihistamine: give
____________________________________________________________________________________
medication/dose/route
Other: give
___________________________________________________________________________________________
medication/dose/route
IMPORTANT: Asthma inhalers and/or antihistamines cannot be depended on to replace epinephrine in anaphylaxis.
STEP 2: EMERGENCY CALLS
1. Call 911 (or Rescue Squad:
________________________ ) . State that an allergic reaction has been treated, and additional epinephrine
may be needed.
2. Dr.
at
____________________________________
____________________________________
3. Emergency contacts:
Name/Relationship
Phone Number(s)
a. ____________________________________________
1.)________________________
2.) ______________________
b. ____________________________________________
1.)________________________
2.) ______________________
c. ____________________________________________
1.)________________________
2.) ______________________
EVEN IF PARENT/GUARDIAN CANNOT BE REACHED, DO NOT HESITATE TO MEDICATE OR TAKE CHILD TO MEDICAL FACILITY!
Parent/Guardian Signature_________________________________________________
Date_______________
Doctor’s Signature_______________________________________________________
Date_______________
(Required)
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