Food Allergy Action Plan printable pdf download

Food Allergy Action Plan

Place

Student’s

Emergency Care Plan

Picture

Here

Name:

D.O.B.:

Allergy to:

Asthma:  Yes (higher risk for a severe reaction)  No

Weight:

lbs.

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.

Any SEVERE SYMPTOMS after suspected or known

1. INJECT EPINEPHRINE

ingestion:

IMMEDIATELY

2. Call 911

One or more of the following:

3. Begin monitoring (see box

LUNG:

Short of breath, wheeze, repetitive cough

below)

HEART:

Pale, blue, faint, weak pulse, dizzy,

4. Give additional medications:*

confused

-Antihistamine

THROAT: Tight, hoarse, trouble breathing/swallowing

-Inhaler (bronchodilator) if

MOUTH:

Obstructive swelling (tongue and/or lips)

asthma

SKIN:

Many hives over body

*Antihistamines & inhalers/bronchodilators

are not to be depended upon to treat a

Or combination of symptoms from different body areas:

severe reaction (anaphylaxis). USE

SKIN:

Hives, itchy rashes, swelling (e.g., eyes, lips)

EPINEPHRINE.

GUT:

Vomiting, diarrhea, crampy pain

MILD SYMPTOMS ONLY:

1. GIVE ANTIHISTAMINE

2. Stay with student; alert

healthcare professionals and

MOUTH:

Itchy mouth

parent

SKIN:

A few hives around mouth/face, mild itch

3. If symptoms progress (see

GUT:

Mild nausea/discomfort

above), USE EPINEPHRINE

4. Begin monitoring (see box

below)

Medications/Doses

Epinephrine (brand and dose):

Antihistamine (brand and dose):

Other (e.g., inhaler-bronchodilator if asthmatic):

Monitoring

Stay with student; alert healthcare professionals and parent. Tell rescue squad epinephrine was given;

request an ambulance with epinephrine. Note time when epinephrine was administered. A second dose of

epinephrine can be given 5 minutes or more after the first if symptoms persist or recur. For a severe reaction,

consider keeping student lying on back with legs raised. Treat student even if parents cannot be reached. See

back/attached for auto-injection technique.

__________________________________

__________

__________________________________

__________

Parent/Guardian Signature

Date

Physician/Healthcare Provider Signature

Date

TURN FORM OVER

Form provided courtesy of the Food Allergy & Anaphylaxis Network ( ) 9/2011

Food Allergy Action Plan

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