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Allergy Action Plan

HomeAllergy Action Plan

Allergy Action Plan

Must be accompanied by a Medication Authorization Form (OCC 1216)

You Can Download Here

Full Name *

Date of Birth *

Month *

Day *

Year *

Allergy to *

Is the child Asthmatic *NoYes(If yes = Higher Risk for Severe Reaction)

Treatment
Symptoms:
The Child has ingested a food allergen or exposed to an allergy trigger

But is not exhibiting or complaining of any symptoms *EpinephrineAnithistamine

Mouth: Itching, tingling, swelling of lips, tongue or mouth ("mouth feels funny") *EpinephrineAnithistamine

Skin: hives, itchy rash, swelling of the face or extremities *EpinephrineAnithistamine

Gut: nausea, abdominal cramps, vomiting, diarrhea *EpinephrineAnithistamine

Throat: difficulty swallowing ("choking feeling"), hoarseness, hacking cough *EpinephrineAnithistamine

Lung: shortness of breath, repetitive coughing, wheezing *EpinephrineAnithistamine

Heart: weak or fast pulse, low blood pressure, fainting, pale, blueness *EpinephrineAnithistamine

Other

If reaction is progressing (several of the above areas affected)

*Potentially life-threatening. The severity of symptoms can quickly change.
*IMPORTANT: Asthma inhalers and/or antihistamines cannot be depended on to replace epinephrine in anaphylaxis.

Medication

Epinephrine *

Antihistamine *

Dose *

Other

Doctor's Signature *

No file chosen

Date

Month

Day

Year

EMERGENCY CALLS

Call 911 (or Rescue Squad) whenever Epinephrine has been administered.
Call the parent. State that and allergic reaction has been treated and additional epinephrine may be needed.
Stay with the child.

Doctor's Name *

Phone Number *

Parent/Guardian 1

Name *

Relationship *

Phone Number(s)

Daytime Number *

Cell *

Parent/Guardian 2

Name

Relationship

Phone Number(s)

Daytime Number

Cell

Emergency 1

Name

Relationship

Phone Number(s)

Daytime Number

Cell

Emergency 2

Name

Relationship

Phone Number(s)

Daytime Number

Cell

*EVEN IF A PARENT/GUARDIAN CANNOT BE REACHED, DO NOT HESITATE TO MEDICATE AND CALL 911.

Health Care Provider and Parent Authorization for Self/Carry Self Administration.
I authorize the child care provider to administer the above medications as indicated.

Students may self carry/self administer [school-aged only] *YesNo

Parent/Guardian's Signature *

No file chosen

Child's Picture Here *

No file chosen

Date *

Month *

Day *

Year *