Child’sname:Dateofplan: Dateofbirth:/_/ Age Weight: kg

Childhasallergyto

Attachchild’sphoto

Childhasasthma.YesNo(Ifyes,higherchanceseverereaction)

Childhashadanaphylaxis.YesNo

Childmaycarrymedicine.YesNo

Childmaygivehim/herselfmedicine.YesNo(Ifchildrefuses/isunabletoself-treat,anadultmustgivemedicine)

IMPORTANTREMINDER

Anaphylaxisisapotentiallylife-threating,severeallergicreaction.Ifindoubt,giveepinephrine.

ForSevereAllergyandAnaphylaxisWhattolookfor
IfchildhasANYoftheseseveresymptomsaftereatingthefoodorhavingasting,giveepinephrine.
  • Shortnessofbreath,wheezing,orcoughing
  • Skincolorispaleorhasabluishcolor
  • Weakpulse
  • Faintingordizziness
  • Tightorhoarsethroat
  • Troublebreathingorswallowing
  • Swellingoflipsortonguethatbotherbreathing
  • Vomitingordiarrhea(ifsevereorcombinedwithothersymptoms)
  • Manyhivesorrednessoverbody
  • Feelingof“doom,”confusion,alteredconsciousness,oragitation
/ Giveepinephrine!Whattodo
1.Injectepinephrinerightaway!Notetimewhenepinephrinewasgiven.
2.Call911.
  • Askforambulancewithepinephrine.
  • Tellrescuesquadwhenepinephrinewasgiven.
3.Staywithchildand:
  • Callparentsandchild’sdoctor.
  • Giveaseconddoseofepinephrine,ifsymptomsgetworse,continue,ordonotgetbetterin5minutes.
  • Keepchildlyingonback.Ifthechildvomitsorhastroublebreathing,keepchildlyingonhisorherside.
4.Giveothermedicine,ifprescribed.Donotuseothermedicineinplaceofepinephrine.
  • Antihistamine
  • Inhaler/bronchodilator

SPECIALSITUATION:Ifthisboxischecked,childhasanextremelysevereallergytoaninsectstingorthefollowingfood(s): .EvenifchildhasMILDsymptomsafterastingoreatingthesefoods,giveepinephrine.

ForMildAllergicReactionWhattolookfor

Ifchildhashadanymildsymptoms,monitorchild.

Symptomsmayinclude:

  • Itchynose,sneezing,itchymouth
  • Afewhives
  • Mildstomachnauseaordiscomfort

MonitorchildWhattodo

Staywithchildand:

  • Watchchildclosely.
  • Giveantihistamine(ifprescribed).
  • Callparentsandchild’sdoctor.
  • Ifsymptomsofsevereallergy/anaphylaxisdevelop,useepinephrine.(See“ForSevereAllergyand

Anaphylaxis.”)

Medicines/Doses

Epinephrine,intramuscular(listtype):

Dose:0.15mg0.30mg(weightmorethan25kg)

Antihistamine,bymouth(typeanddose): Other(forexample,inhaler/bronchodilatorifchildhasasthma):

Parent/GuardianAuthorizationSignatureDatePhysician/HCPAuthorizationSignatureDate

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Child’sname:Dateofplan:

AdditionalInstructions:

Contacts

Call911/Rescuesquad:()-

Doctor:

Phone:()-

Parent/Guardian:

Phone:(_ )-

Parent/Guardian:

Phone:(_ )-

OtherEmergencyContacts

Name/Relationship:

Phone:( _)-

Name/Relationship:

Phone:(_ )-

©2017AmericanAcademyofPediatrics.Allrightsreserved.Yourchild’sdoctorwilltellyoutodowhat’sbestforyourchild.Thisinformationshouldnottaketheplaceoftalkingwithyourchild’sdoctor.Page2of2.