SEVERE ALLERGY ACTION PLAN (ANAPHYLAXIS)

Student’s Name: ______DOB: ______Grade: ______

ALLERGY TO: ______

Asthmatic:  NO  YES Higher risk for severe reaction

Symptoms: Give Checked Medication

(To be determined by physician authorizing treatment)

  • If exposed to allergen, but no symptoms:  Epi-Pen Antihistamine
  • Mouth: Itching, tingling, or swelling of lips, tongue, mouth Epi-Pen Antihistamine
  • Skin: Hives, itchy rash, swelling of face or extremities Epi-Pen Antihistamine
  • Gut:Nausea, abdominal cramps, vomiting, diarrhea Epi-Pen Antihistamine
  • Throat: †Tightening of throat, hoarseness, hacking cough Epi-Pen Antihistamine
  • Lung: †Shortness of breath, repetitive coughing, wheezing Epi-Pen Antihistamine
  • Heart: †Fainting, pale, blueness, thready pulse, low BP Epi-Pen Antihistamine
  • Other: † ______ Epi-Pen Antihistamine
  • If reaction is progressing (several of the above areas affected) Epi-Pen Antihistamine

The severity of symptoms can quickly change. † Potentially Life Threatening

DOSAGE

Epinephrine / Epi-Pen: Inject intramuscularly Epi-Pen 0.3 mg Epi-Pen Jr. 0.15 mg  Repeat in 10 mins. PRN

Antihistamine: give  Benadryl  50 mg po OR swish & swallow  25 mg po OR swish & swallow

Antihistamine Other:______po OR swish & swallow

Name of Medication Dose

Health Care Provider: My signature provides authorization to administer the above prescribed medications at school. Student may carry and self administer the above prescribed medication?  YES  NO

Authorization Begins: ______Ends: ______

Month / Day / YearMonth / Day / Year

______

HEALTH CARE PROVIDER SIGNATURE PRINTED NAME PHONE NUMBER

PARENT/GUARDIAN AUTHORIZATION

I want this allergy plan implemented for my child; I want my child to carry the Epi Penand/or Benadryl. I understand that my child will carry this medication on them at all times during field trips and / or after school activities.

It is recommended that a backup medication be stored with the school nurse in case a student forgets or loses his or her medication. The school district is not responsible or liable if backup medication is not provided to the school and my child is without working medication when medication is needed.

I want this plan implemented for my child and I Do NOT want my child to carry and self-administer Epi-Pen and/or Benadryl. I have provided sufficient amounts of this medication to be stored by the school nurse for my child’s use. I understand the nurse will provide this medication to trained school personnel for use during field trips and after school activities.

I have checked the appropriate box above and give permission for the nurse to contact and receive additional information from my healthcare provider regarding the allergic condition(s) and the prescribed medication.

Parent/Guardian Signature: ______Date: ______

STUDENT AGREEMENT:

I have been trained in the use of my Epi-Pen and allergy medications and understand the signs and symptoms for which they are given;

I agree to carry my Epi Pen with me at all times during field trips and after school activities.

I will notify a responsible adult (teacher, nurse, coach, chaperone etc.) IMMEDIATELY when my auto-injector EpiPen has been used.

I will not share my medication with other students or leave my Epi-Pen unattended

I will not use my allergy medications for any other use than what it is prescribed for.

Student Signature: ______Date: ______