Life Threatening Emergency Medical Form For School And Transportation Use (Page 2 of 2) in pdf

Emergency Action Plan

Name of Student: ________________________________

EMERGENCY ACTION PLAN: List steps to be taken in a concise and legible format

Medical Condition – Specific Allergy – Please Check All That Apply

Indications of Severe Allergic Reaction:



Difficulty breathing or swallowing, wheezing, coughing, choking

Loss of consciousness/passes out



Flushed face, hives, swelling or itching lips, tongue, eyes

Tightness in throat, mouth, chest



Dizziness, unsteadiness, sudden fatigue, rapid heartbeat

Pale blue skin or lips



Vomiting, nausea, diarrhea, stomach pains

Other (identify): _______________________

_____________________________________

Medical Condition – Asthma – Please Check All That Apply

Indications of Severe Asthmatic Reaction:

 Restlessness, irritability, fatigue, coughing (frequent, dry and



Wheezing (can’t always hear it)

regular)

 Breathlessness (child may talk in one or two word sentences;



Breathing quickly

nostrils flaring with breaths)

 Obvious discomfort



Constantly rubbing nose or throat

 Neck muscles tighten every time they breathe



Other (identify): ______________________

 Lips and nail beds may have a grayish or bluish colour

____________________________________

Asthma Triggers:

 cold/flu/illness  mould  dust  cold weather  strong smells  pet dander  cigarette smoke

 physical activity/exercise  pollen  allergies (specify):________________________________________

Medical Condition – Diabetes – Please Check All That Apply

Possible Symptoms of Low Blood Sugar in Diabetics:

* More likely when activity changes (field trip or track day etc.) or if meal time is missed or schedule changes.



confusion

shakes

crying

increased heart rate



trembling

hunger

feeling low

numbness or tingling of



headache

withdrawn, quiet

pale

tongue or lips



sweating

weak, drowsy

irritable, anxious

nauseated

* May lead to loss of consciousness (passing out) or seizures

Possible Symptoms of High Blood Sugar in Diabetics:

* More rare



increased thirst

increased urination

feeling unwell

Medical Condition – Epileptic Seizure – Please Check All That Apply

Symptoms of Epileptic Seizures:



Staring, apparently not hearing, no movement

Jerking of the arms, legs, face



Twitching

Drowsiness or inattention



Drooling or biting lips, cheeks or tongue

May become unconscious

Instructions for bus driver in the event of an epileptic seizure:

DO NOT put anything in the child’s mouth. DO NOT restrain movement. If possible, put something soft under the head

for protection. AFTER THE SEIZURE put the child on their side in recovery position. If a seizure lasts longer than 5

minutes, or repeats without full recovery, SEEK MEDICAL ASSISTANCE IMMEDIATELY.

Reviewed: June 2016

Administrative Procedure – B1:2

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