Allergy Action Plan Template
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3PRINCE GEORGE COUNTY PUBLIC SCHOOLS
Allergy Action Plan
Page 1 of 3
Student’s Name: ________________________________________ DOB: _____________________ Weight (pounds):____________
School: ____________________________School Year: _______________
ALLERGY TO: _____________________________________________________________________________________
_____________________________________________________________________
Symptoms of Previous Reactions:
Does child have asthma?
Yes*
No
*Higher risk for severe reaction if asthmatic
S y mp t oms of a n Al l e r gi c Re ac ti on:
* *G i ve C he c k e d M e di c at i on
(to be determined by physician/licensed prescriber)
•
If a food allergen has been ingested, but NO SYMPTOMS
Epinephrine
Antihistamine
•
If stung by a bee, but NO SYMPTOMS
Epinephrine
Antihistamine
•
Mouth
Itching, tingling, or swelling of lips, tongue, mouth
Epinephrine
Antihistamine
•
Skin
Hives, itchy rash, swelling of 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 †
Weak or thready pulse, low blood pressure, fainting, pale, blueness
Epinephrine
Antihistamine
•
Other †
__________________________________________________
Epinephrine
Antihistamine
•
If a reaction is progressing (several of the above areas affected), give:
Epinephrine
Antihistamine
† Potentially Life Threatening. The severity of symptoms can quickly change.
TREATMENT AND MEDICATION ORDER:
Epinephrine (Circle Correct Dosage):
EpiPen® (0.3 mg)
EpiPen Jr.® (0.15 mg)
If symptoms continue, give second dose 5 to 15 minutes after first dose.
Antihistamine (Medication/Dose/Frequency) _________________________________________________________________
Call 911. State that an allergic reaction has been treated, and additional epinephrine may be needed. Stay with
student until emergency medical services arrive. Monitor airway, breathing, and pulse. Administer CPR if
needed. Direct someone to notify parent or guardian. Provide EMS or parent/guardian with used epinephrine
auto-injector labeled with name, date, and time given to take to hospital with student.
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 MY CHILD TO MEDICAL FACILITY!
Student has been instructed in the proper use of auto-injectable epinephrine, has demonstrated proper use and may carry his/her own auto-injectable
epinephrine at school.
Student should NOT carry his/her auto-injectable epinephrine at school.
Parent/Guardian Signature _______________________________________________________________________ Date __________________________________
Physician/Prescriber Signature ____________________________________________________________________ Date __________________________________
Physician/Prescriber PRINTED Name_________________________________________ Phone__________________________ FAX_________________________
HSM 0001-0915
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