Report Of Epinephrine Administration Form - Haywood County Schools
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2Haywood County Schools
Report of Epinephrine Administration
Student Demographics and Health History
1. Name of School: _____________________________________________________
2. Age: ______ Type of Person: Student
Staff
Visitor
Gender: M
F
3. History of allergy: Yes
No
Unknown
If known, specify type of allergy: ____________________________________________
If yes, was allergy action plan in place
Yes
No
Unknown
History of anaphylaxis:
Yes
No
Unknown
Previous epinephrine use:
Yes
No
Unknown
Diagnosis/History of asthma: Yes
No
Unknown
School Plans and Medical Orders
4. Individual Health Care Plan (IHCP) in place? Yes
No
Unknown
5. Written school policy on management of life-threatening allergies in place? Yes
No
Unknown
6. Does the student have a student specific order for epinephrine? Yes
No
Unknown
7. Expiration date of epinephrine _____________________
Unknown
Epinephrine Administration Incident Reporting
8. Date/Time of occurrence: _________________________Vital signs: BP_____/____ Temp ______ Pulse __________ Respiration _________
9. If known, specify trigger that precipitated this allergic episode:
Food
Insect Sting
Exercise
Medication
Latex
Other
_________________________ Unknown
If food was a trigger, please specify which food ______________________________________________________________________________
Please check: Ingested
Touched
Inhaled
Other
specify ____________________________________________________
10. Did reaction begin prior to school? Yes
No
Unknown
11. Location where symptoms developed:
Classroom
Cafeteria
Health Office
Playground
Bus
Other
specify _____________________________________
12. How did exposure occur?
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
13. Symptoms: (Check all that apply)
Respiratory
GI
Skin
Cardiac/Vascular
Other
Cough
Abdominal discomfort
Angioedema
Chest discomfort
Diaphoresis
Difficulty breathing
Diarrhea
Flushing
Cyanosis
Irritability
Hoarse voice
Difficulty swallowing
General pruritis
Dizziness
Loss of consciousness
Nasal congestion/rhinorrhea
Oral Pruritis
General rash
Faint/Weak pulse
Metallic taste
Swollen (throat, tongue)
Nausea
Hives
Headache
Red eyes
Shortness of Breath
Vomiting
Lip swelling
Hypotension
Sneezing
Stridor
Localized rash
Tachycardia
Uterine cramping
Tightness (chest, throat)
Pale
Wheezing
14. Location where epinephrine administered: Health Office
Other
specify ___________________________________________________
Rev 3/14
Please complete all pages.
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