Food Allergy & Anaphylaxis Emergency Care Plan
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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 allergens: _________________________________________________________
THEREFORE:
[ ] If checked, give epinephrine immediately if the allergen was LIKELY eaten, for ANY symptoms.
[ ] If checked, give epinephrine immediately if the allergen was DEFINITELY eaten, even if no symptoms are apparent.
MILD SYMPTOMS
FOR ANY OF THE FOLLOWING:
SEVERE SYMPTOMS
NOSE
MOUTH
SKIN
GUT
LUNG
HEART
THROAT
MOUTH
Itchy or
Itchy mouth
A few hives,
Mild
runny nose,
mild itch
nausea or
Shortness of
Pale or bluish
Tight or hoarse
Significant
sneezing
discomfort
breath, wheezing,
skin, faintness,
throat, trouble
swelling of the
repetitive cough
weak pulse,
breathing or
tongue or lips
FOR MILD SYMPTOMS FROM MORE THAN ONE
dizziness
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 emergency dispatcher the person is having
MEDICATIONS/DOSES
anaphylaxis and may need epinephrine when emergency
responders arrive.
Epinephrine Brand or Generic: ________________________________
•
Consider giving additional medications following epinephrine:
»
Antihistamine
Epinephrine Dose:
[ ] 0.15 mg IM
[ ] 0.3 mg IM
Inhaler (bronchodilator) if wheezing
»
•
Lay the person flat, raise legs and keep warm. If breathing is
Antihistamine Brand or Generic: _______________________________
difficult or they are vomiting, let them sit up or lie on their side.
Antihistamine Dose: __________________________________________
•
If symptoms do not improve, or symptoms return, more doses of
epinephrine can be given about 5 minutes or more after the last dose.
Other (e.g., inhaler-bronchodilator if wheezing): __________________
•
Alert emergency contacts.
•
Transport patient to ER, even if symptoms resolve. Patient should
____________________________________________________________
remain in ER for at least 4 hours because symptoms may return.
PATIENT OR PARENT/GUARDIAN AUTHORIZATION SIGNATURE
DATE
PHYSICIAN/HCP AUTHORIZATION SIGNATURE
DATE
FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) () 4/2017
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