Allergies/anaphylaxis Medication Administration Form

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ALLERGIES/ANAPHYLAXIS MEDICATION ADMINISTRATION FORM
Provider Medication Order Form—Office of School Health —School Year 2017–2018
Date of birth
(kg)
Student Last Name
First Name
Middle
Weight
Male
A
S
P
.
TTACH
TUDENT
HOTO HERE
Female
__ __ / __ __/ __ __ __ __
__ __ __
__
M M
D D
Y Y Y Y
#
__ __ __ __ __ __ __ __ __
OSIS
School (include name, number, address and borough)
DOE District
Grade
Class
___ ___
The following section to be completed by Student’s HEALTH CARE PRACTITIONER
Specify Allergy
Specify Allergy
Specify Allergy
Allergy to
Allergy to
Allergy to
History of asthma?
Yes (If yes, student has an increased risk for a severe reaction)
No
Does this student have the ability to:
History of anaphylaxis?
Yes Date
No
Self-Manage
Yes
No
__ __ / __ __/ __ __ __ __
If yes, symptoms
Respiratory
Skin
GI
Cardiovascular
Neurologic
Recognize signs of allergic reactions
Yes
No
Treatment
Date
Recognize/avoid allergens independently
Yes
No
__ __ / __ __/ __ __ __ __
Yes (attach copy of results)
Date
No
History of skin testing?
Comments:
__ __ / __ __/ __ __ __ __
Select In School Medications
In School Instructions
1.
PRN (check all that apply):
-
S
ONLY SINGLE DOSE AUTO
INJECTORS
ELECT BELOW
Epinephrine Auto-Injector 0.15 mg
Itching
Shortness of Breath
Vomiting / Diarrhea
Epinephrine Auto-Injector 0.3 mg
Hives
Tightness / Closure
Weak Pulse
Give antihistamine in addition to epinephrine (must order antihistamine
Swelling
Hoarseness
Pallor / Cyanosis
below)
Redness
Wheezing
Dizziness / Fainting
Select the most appropriate option for this student:
Specify signs, symptoms, or situations:
Nurse-Dependent Student: nurse or trained school personnel must administer
Supervised Student: student self-administers, under adult supervision
 Administer Intramuscularly into anterolateral aspect of thigh
Independent Student: student is self-carry/self-administer **
 Call 911 immediately
If no improvement, repeat in ___ minutes for a maximum of __ times (not to
I attest student demonstrated ability to self-administer the
exceed a total of 3 doses).
_________
prescribed medication effectively for school/field trips/school-
Practitioner’s initials
sponsored events **
PARENT MUST INITIAL REVERSE
2.
O
M
: □ Diphenhydramine
PRN (check all that apply):
RAL
EDICATION
Preparation/Concentration: _______________ Route ___________________
Itchy Mouth
Few Hives
Itchy / Runny
Mildly Itchy Skin
Mild Nausea / Discomfort
Select the most appropriate option for this student:
Nose
Nurse-Dependent Student: nurse must administer
Sneezing
Supervised Student: student self-administers, under adult supervision
Specify signs, symptoms, or situations:
Independent Student: student is self-carry/self-administer **
Dose: _________  4 hours or  6 hours as needed (specify)
I attest student demonstrated ability to self-administer the
If no improvement, indicate instructions:
prescribed medication effectively for school/field trips/school-
_________
sponsored events **
Practitioner’s initials
PARENT MUST INITIAL REVERSE
3.
O
M
:
___________________________________
PRN Specify signs, symptoms, or situations:
RAL
EDICATION
Preparation/Concentration: _______________ Route ___________________
Select the most appropriate option for this student:
Dose: _________ Time interval: ___ (specify min or hours)
Nurse-Dependent Student: nurse must administer
Conditions under which medication should not be given:
Supervised Student: student self-administers, under adult supervision
Independent Student: student is self-carry/self-administer **
If no improvement, indicate instructions:
I attest student demonstrated ability to self-administer the
prescribed medication effectively for school/field trips/school-
_________
sponsored events **
Practitioner’s initials
PARENT MUST INITIAL REVERSE
HOME Medications (include over-the counter)
For Office of School Health (OSH) Use Only
 IEP
Revisions per OSH after consultation with prescribing practitioner.
Health Care Practitioner
Signature
LAST NAME
FIRST NAME
(Please Print)
Address
Tel.
Fax.
( __ __ __ ) __ __ __ - __ __ __ __
( __ __ __ ) __ __ __ - __ __ __ __
E-mail address
Cell
( __ __ __ ) __ __ __ - __ __ __ __
NYS License # (Required)
NPI #
Date
______________________
__ __ / __ __ / __ __ __ __
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
INCOMPLETE PRACTITIONER INFORMATION WILL DELAY IMPLEMENTATION OF MEDICATION ORDERS
TURN TO PAGE 2 
FORMS CANNOT BE COMPLETED BY A RESIDENT
Rev 4/17

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