History of Anaphylaxis: Yes No If Yes, Was Anaphylaxis Known by the School? Yes No

Name of Student:School:
Age:DOB: M  F Spanish/Hispanic/Latino: Yes No 

African American White Asian  Am. Indian/Alaskan Native  Hawaiian/Other Pacific Islander Other
History of severe or life-threatening allergy: Yes  No If known, specify type of allergy:
If yes, was the allergy known by the school? Yes  No 

History of anaphylaxis: Yes  No If yes, was anaphylaxis known by the school? YesNo 

Previous epinephrine use: Yes No If yes, was epinephrine administered at school? YesNo 

Diagnosis/history of asthma:YesNo If yes, was asthma rescue inhaler available? YesNo Asthma EAP?Yes No

Allergy/AnaphylaxisIHP/EAP in place? YesNo Specific order for epinephrine? Yes No Available at school?Yes No

Incident Date Timea.m.  p.m. Reaction began: before  during  after school.
Trigger that precipitated the allergic episode, if known: Food Insect Sting Latex Medication Exercise Unknown
If food was a trigger, specify which food:______other:

If food was a trigger, specify if food was: Ingested Touched Inhaled Unknown Other:
How did exposure occur?
Symptoms developed: Classroom Cafeteria Health Office Playground PE Athletic field Bus other

Symptoms: (Check all that apply)

RespiratoryGastro-Intestinal Skin Cardiac/Vascular Other
 Cough  Abdominal discomfort Swelling  Chest discomfort  Diaphoresis
 Difficulty breathing  Diarrhea  Flushing  Cyanosis  Irritability

 Hoarse voice  Difficulty swallowing General itching  Dizziness  Loss of consciousness

 Congestion/runny nose Mouth itching General rash  Faint/Weak pulse  Metallic taste

 Swollen (throat, tongue)  Nausea  Hives  Headache  Red eyes

 Shortness of Breath  Vomiting Lip swelling  Hypotension  Sneezing

 High-pitched breathing Localized rash Tachycardia

 Tightness (chest, throat) Pale

 Wheezing

Epinephrine Administered:ClassroomCafeteriaHealth RoomPlaygroundPE Athletic FieldBusother:

1st dose of epinephrine given by: EMSStudent (self)  School Nurse 1stResponder Coach/PE teacherother:
Time: 1st dosea.m.p.m. Notification of: EMSa.m. p.m. Parent/Legal Guardian:a.m.  p.m. 

Was a 2nddose of epinephrine required? Yes NoUnknown If yes, time 2nd dose administered: a.m.  p.m. 

2nddose administered by: EMS Student (self)  School Nurse 1stResponder Coach/PE teacher other

Did rebound of symptoms occur (biphasic reaction)? Yes  No  Unknown 
Time EMS transported to ER:a.m.  p.m.  Hospitalized? Yes  No  Unknown 

Parent/Legal Guardian: Arrived at school before EMS transport  Met EMS/student at hospital other:

Was an epinephrine auto-injector prescribed? Yes  No  Allergy/Anaphylaxis IHP/EAP provided for school? Yes  No 

Form completed by (name/title):Date:

Form reviewed by principal:Date: