Health Form 102a - Allergy/anaphylaxis Action Plan
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1
2H
102
(3/05/07)
EALTH FORM
A
A
/A
A
P
LLERGY
NAPHYLAXIS
CTION
LAN
Student
Student Name ________________________ D.O.B. _________ Teacher ____________
Photo
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:
Epinephrine
Antihistamine
No symptoms noted
Observe for other symptoms
Mouth
Itching, tingling, or swelling of lips, tongue, mouth
Skin
Hives, itchy rash, swelling of the face or extremities
Gut+
Nausea, abdominal cramps, vomiting, diarrhea
Throat+
Tightening of throat, hoarseness, hacking cough
Lung+
Shortness of breath, repetitive coughing, wheezing
Thready pulse, low BP, fainting, pale, blueness
Heart+
Neuro+
Disorientation, dizziness, loss of consciousness
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
0.3 mg OR
0.15 mg
Antihistamine: Diphenhydramine (Benadryl®) ______ml. To be given by mouth only if able to swallow.
Other:
This child has received instruction in the proper use of the Auto-injector: EpiPen® or Twinject® (circle one). It
is my professional opinion that this student SHOULD be allowed to carry and use the auto-injector independently.
The child knows when to request antihistamine and has been advised to inform a responsible adult if the auto-
injector is self-administered.
It is my professional opinion that this student SHOULD NOT carry an auto-injector.
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.
Rev. 7/06
This form is adapted from The Food Allergy Anaphylaxis Network, “Food Allergy Action Plan” & the Asthma and Allergy Foundation of America, AK Chapter
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