Allergy Action Plan Form

ADVERTISEMENT

Allergy Action Plan
Participant’s Name: __________________________________Program:______________
ALLERGY TO: _________________________________________________________
Asthmatic
Yes*_____
No _____
*Higher risk of severe reaction
STEP 1: TREATMENT
Symptoms:
Give Checked Medication
___EpiPen ___Antihistamine ___Auvi-Q ___Do Nothing
If a food allergen has been ingested, but no symptoms
Mouth- Itching, tingling, or swelling of lips, tongue, mouth
___EpiPen ___Antihistamine ___Auvi-Q ___Do Nothing
Skin – Hives, itchy rash, swelling of the face or extremities
___EpiPen ___Antihistamine ___Auvi-Q ___Do Nothing
Stomach – Nausea, abdominal cramps, vomiting, diarrhea
___EpiPen ___Antihistamine ___Auvi-Q ___Do Nothing
Throat – Tightening of throat, hoarseness, hacking/coughing
___EpiPen ___Antihistamine ___Auvi-Q ___Do Nothing
Lung – Shortness of breath, repetitive coughing, wheezing
___EpiPen ___Antihistamine ___Auvi-Q ___Do Nothing
Heart–Thready pulse, low blood pressure, fainting, pale, blueness
___EpiPen___Antihistamine ___Auvi-Q ___Do Nothing
Other - ________________________________________
___EpiPen ___Antihistamine ___Auvi-Q ___Do Nothing
If reaction is progressing (several of the above areas affected) give
___EpiPen___Antihistamine___Auvi-Q___Do Nothing
Dosage:
Epinephrine: inject intramuscularly (circle one)
EpiPen
EpiPen Jr
Auvi-Q
Antihistamine: give ______________________________________________________
Medicine/dose/route
Other: give______________________________________________________________
Medicine/dose/route
STEP 2: EMERGENCY CALLS
1. Staff will call 911 if ___EpiPen ___Antihistamine ___Auvi-Q is given
2. Emergency Contacts if
___EpiPen ___Antihistamine ___Auvi-Q is given
Name
Relationship
Phone Number
_____________________
_________________
__________________
_____________________
_________________
__________________
_____________________
_________________
__________________
If a parent or emergency cannot be reached when an ambulance arrives a staff member
will accompany the child to the hospital.
Parent/Guardian Signature _____________________________________
Date: ____________

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Food Allergy Action Plan Form Food Allergy Action Plan Form Business
Health Form 102a - Allergy/anaphylaxis Action Plan Health Form 102a - Allergy/anaphylaxis Action Plan Business
Severe Allergy/anaphylaxis Action Plan And Treatment Authorization Form Severe Allergy/anaphylaxis Action Plan And Treatment Authorization Form Business
Emergency Action Plan And Order Form: Severe Allergy In School - Mecklenburg County Health Department Emergency Action Plan And Order Form: Severe Allergy In School - Mecklenburg County Health Department Medical
Allergy Action Plan Template Allergy Action Plan Template Business
Performance Action Plan Form Performance Action Plan Form Business
Diabetes Action Plan Form Diabetes Action Plan Form Medical
Asthma Action Plan Form Asthma Action Plan Form Business
Food Allergy Action Plan Template Food Allergy Action Plan Template Business
Food Allergy Action Plan Food Allergy Action Plan Business

Related Categories

Parent category: Business
Download
Go