Medication Administration Record - Allergy/epi-Pen Form
ADVERTISEMENT
1
2School Year _________________
Medication Administration Record – Allergy/Epi-pen Form
Student Photo
Student Information
Student Name:
Date of Birth:
Grade:
Student Address:
Phone:
Teacher:
Food Allergies:
Other Allergies:
Prescriber Authorization
Medication
Dosage, Route & Time
Possible Severe Adverse Reactions as
Special Instructions
required per ORC 3313.716
□ Standard order: inject intramuscularly
Possible severe adverse reactions for the
Special instructions:
Diagnosis: _______________________
into the lateral aspect of the thigh.
student to whom it is prescribed:
□ See Allergy Action Plan
________________________________
Time:
Medication:
□ Student may self-carry & self-
□ EpiPen
®
□ if a food allergen has definitely been
Jr. Autoinjector0.15mg/0.3ml
________________________________
administer Epi-pen (must complete
□ EpiPen
®
Autoinjector 0.3 mg/0.3ml
eaten but no symptoms.
separate form)
□ Other epinephrine autoinjector
□ if child has any of the following
□ Student may self-carry and a back-up
____________________________
symptoms (check all that apply):
Possible severe adverse reactions for the
dose is ordered for the nurse’s office.
student to whom it is NOT prescribed:
□ itching, tingling, swelling of lips, tongue,
® &
®
Note: EpiPen
EpiPen
Jr. each contain 2ml
□ Procedures to follow if medication
epinephrine solutions. Solution will remain in the
mouth
________________________________
does not produce relief:
autoinjector and cannot be reused.
□ shortness of breath, wheezing, tightness of
throat
________________________________
________________________________
Begin date: ___________________
□ hoarseness, repetitive or hacking cough
□ thread pulse, fainting, pale, bluish skin/lips
□ hives, itching, swelling of face or extremities
________________________________
End date (if other than end of school
□ nausea, vomiting, abdominal cramps, diarrhea
year) ________________________
□ Other:
Possible sever adverse reactions
reportable to the prescriber:
________________________________
________________________________
_______________________________
Home Medications: ______________
Prescriber Name (print):
Prescriber Signature & Date:
Prescriber phone & address:
________________________________
____________________________________
________________________________
________________________________
8401 Montgomery Road Cincinnati, OH 45236 Phone: 513-984-3770 Fax: 513-984-3787
Page 1 (over)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical