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NO. 209.1 ATTACHMENT 1
CENTRAL CAMBRIA SCHOOL DISTRICT
Emergency Health Care Plan and Medication Orders for Life Threatening Allergies
Student Name: _______________________________________________________Date of Birth: _____________________School Year: __________________
School: _____________________________________________________________ Grade: _____________ Unit Teacher: ______________________________
YES
NO
Allergy to: _____________________________________________________________________________________ Asthmatic:
STEP 1: TREATMENT – To be completed by Physician
Symptoms:
Give Checked Medication (to be determined by
physician)
If exposure to an allergen occurs, but no symptoms
Epinephrine
Antihistamine
~Mouth
Itching, tingling, or swelling of lips, tongue, mouth
Epinephrine
Antihistamine
~Skin
Hives, itchy rash, swelling of the face or extremities
Epinephrine
Antihistamine
~Gut
Nausea, abdominal cramps, vomiting, diarrhea
Epinephrine
Antihistamine
~Throat* Tightening of throat, hoarseness, hacking cough
Epinephrine
Antihistamine
~Lungs* Shortness of breath, repetitive coughing, wheezing
Epinephrine
Antihistamine
~Heart* Weak or thread pulse, low blood pressure, fainting, pale, blueness
Epinephrine
Antihistamine
~Other*
Epinephrine
Antihistamine
~If reaction is progressing (several of the above areas affected), give:
Epinephrine
Antihistamine
*Potentially life-threatening. The severity of symptoms can quickly change.
DOSAGE:
Epinephrine – Inject intramuscularly:
Epi-Pen 0.3 mg.
Epi-Pen Jr. 0.15 mg.
Antihistamine – give (medication/dose/route):
Benadryl
__________mg.
Repeat Epi-Pen
YES
NO
in 15 minutes if squad has not arrived – 2 kits will be needed in school.
STEP 2: EMERGENCY CALLS – To be completed by Parent/Guardian
1. Call 911 for Rescue Squad and ask for Advanced Life Support – state that an allergic reaction has been treated.
2. Call: Mother: Home: _________________________________ Work: __________________________________ Cell: ____________________________
Father: Home: _________________________________ Work: __________________________________ Cell: ____________________________
Emergency Contacts:
First: Name: ____________________________________ Relationship: _____________________________ Phone #: ________________________
Second: Name: __________________________________ Relationship: _____________________________ Phone #: ________________________
3. Physician: _____________________________________________________________________________________ Phone #: _______________________
4. Preferred Hospital: _______________________________________________________________________________ Phone #: _______________________
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