Allergy/anaphylaxis Action Plan Template
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P
LLERGY
NAPHYLAXIS
CTION
LAN
Student
Photo
Student Name ________________________ D.O.B. _________ Teacher ____________
School Nurse_________________________________ Phone Number _________________________________
Health Care Provider ___________________________ Preferred Hospital _____________________________
History of Asthma
No
Yes-Higher risk for severe reaction
ALLERGY: (check appropriate) To be completed by Health Care Provider
Foods (list):
Medications (list):
Latex:
Circle: Type I (anaphylaxis) Type IV (contact dermatitis)
Stinging Insects (list):
RECOGNITION AND TREATMENT
Chart to be completed by Health Care Provider ONLY
Give CHECKED Medication
If food ingested or contact w/ allergen occurs:
EpiPen
Antihistamine
No symptoms noted
Observe for other symptoms
Itching, tingling, or swelling of lips, tongue, mouth
Mouth
Hives, itchy rash, swelling of the face or extremities
Skin
Nausea, abdominal cramps, vomiting, diarrhea
Gut+
Throat+
Tightening of throat, hoarseness, hacking cough
Shortness of breath, repetitive coughing, wheezing
Lung+
Thready pulse, low BP, fainting, pale, blueness
Heart+
Disorientation, dizziness, loss of conscience
Neuro+
If reaction is progressing (several of the above areas affected), GIVE:
The severity of symptoms can quickly change. +Potentially life-threatening.
DOSAGE:
Epinephrine: Inject into outer thigh
EpiPen 0.3 mg OR
EpiPen Jr. 0.15 mg
(see reverse for instructions)
Antihistamine: Benadryl ________________mg To be given by mouth only if able to swallow.
Other:
This child has received instruction in the proper use of the EpiPen. It is my professional opinion that this
student SHOULD be allowed to carry and use the EpiPen independently. The child knows when to request
antihistamine and has been advised to inform a responsible adult if the EpiPen is self-administered.
It is my professional opinion that this student SHOULD NOT carry the EpiPen.
Health Care Provider Signature
______________________ Phone: ______________ Date ________
EMERGENCY CALLS
1. Call 911. State that an allergic reaction has been treated, and additional epinephrine may be needed.
2. Call parents/guardian to notify of reaction, treatment and student's health status.
3. Treat for shock. Prepare to do CPR.
4. Accompany student to ER if no parent/guardians are available.
PREVENTION:
Avoidance of allergen is crucial to prevent anaphylaxis. Critical components to prevent
life threatening reactions:
Indicates activity completed by school staff
Encourage the use of Medic-alert bracelets
Notify nurse, teacher(s), front office and kitchen staff of known allergies
Use non-latex gloves and eliminate powdered latex gloves in schools
Ask parents to provide non-latex personal supplies for latex allergic students
Post “Latex reduced environment” sign at entrance of building
Encourage a no-peanut zone in the school cafeteria
Other:
Rev. 08/05
This form is adapted from The Food Allergy Anaphylaxis Network, “Food Allergy Action Plan” by the Alaska Asthma Coalition.
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