Food Allergy & Anaphylaxis Emergency Care Plan Form
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Name: _________________________________________________________________________ D.O.B.: ____________________
PICTURE
HERE
Allergy to: __________________________________________________________________________________________________
[ ] Yes (higher risk for a severe reaction) [ ] No
Weight: ________________ lbs. Asthma:
NOTE: Do not depend on antihistamines or inhalers (bronchodilators) to treat a severe reaction. USE EPINEPHRINE.
Extremely reactive to the following foods: ____________________________________________________________
THEREFORE:
[ ] If checked, give epinephrine immediately for ANY symptoms if the allergen was likely eaten.
[ ] If checked, give epinephrine immediately if the allergen was definitely eaten, even if no symptoms are noted.
MILD SYMPTOMS
FOR ANY OF THE FOLLOWING:
SEVERE SYMPTOMS
NOSE
MOUTH
SKIN
GUT
LUNG
HEART
THROAT
MOUTH
Itchy/runny
Itchy mouth
A few hives,
Mild nausea/
nose,
mild itch
discomfort
Short of breath,
Pale, blue,
Tight, hoarse,
Significant
sneezing
wheezing,
faint, weak
trouble
swelling of the
repetitive cough
pulse, dizzy
breathing/
tongue and/or lips
FOR MILD SYMPTOMS FROM MORE THAN ONE
swallowing
SYSTEM AREA, GIVE EPINEPHRINE.
OR A
FOR MILD SYMPTOMS FROM A SINGLE SYSTEM
COMBINATION
AREA, FOLLOW THE DIRECTIONS BELOW:
SKIN
GUT
OTHER
of symptoms
from different
Many hives over
Repetitive
Feeling
1. Antihistamines may be given, if ordered by a
body areas.
body, widespread
vomiting, severe
something bad is
healthcare provider.
redness
diarrhea
about to happen,
2. Stay with the person; alert emergency contacts.
anxiety, confusion
3. Watch closely for changes. If symptoms worsen,
give epinephrine.
INJECT EPINEPHRINE IMMEDIATELY.
1.
Call 911.
2.
Tell them the child is having anaphylaxis and may
MEDICATIONS/DOSES
need epinephrine when they arrive.
•
Consider giving additional medications following epinephrine:
Epinephrine Brand: __________________________________________
»
Antihistamine
»
Inhaler (bronchodilator) if wheezing
Epinephrine Dose:
[ ] 0.15 mg IM
[ ] 0.3 mg IM
•
Lay the person flat, raise legs and keep warm. If breathing is
difficult or they are vomiting, let them sit up or lie on their side.
Antihistamine Brand or Generic: _______________________________
•
If symptoms do not improve, or symptoms return, more doses of
Antihistamine Dose: __________________________________________
epinephrine can be given about 5 minutes or more after the last dose.
•
Alert emergency contacts.
Other (e.g., inhaler-bronchodilator if wheezing): __________________
•
Transport them to ER even if symptoms resolve. Person should
____________________________________________________________
remain in ER for at least 4 hours because symptoms may return.
PARENT/GUARDIAN AUTHORIZATION SIGNATURE
DATE
PHYSICIAN/HCP AUTHORIZATION SIGNATURE
DATE
FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) ( ) 3/2016
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