Microsoft word - asd allergy handbook.doc

Student Allergy/Anaphylaxis Action Plan
Student Name _____________________ D.O.B. _________ Teacher _____________
School Nurse______________________________ Phone Number ___________________
Health Care Provider ____________________ Preferred Hospital __________________
History of Asthma No Yes-Higher risk for severe reaction
ALLERGY: (check appropriate) To be completed by Health Care Provider
Foods (list):
Medications (list):
Latex: Circle: Type I (anaphylaxis) Type IV (contact dermatitis)
Stinging Insects (list):
Chart to be completed by Health Care Provider ONLY
Give CHECKED Medication
If food ingested or contact w/allergen occurs: Itching, tingling, or swelling of lips, tongue, mouth Hives, itchy rash, swelling of the face or extremities Nausea, abdominal cramps, vomiting, diarrhea Tightening of throat, hoarseness, hacking cough Shortness of breath, repetitive coughing, wheezing Thready pulse, low BP, fainting, pale, blueness Disorientation, dizziness, loss of consciousness If reaction is progressing (several of the above areas affected), GIVE:
The severity of symptoms can quickly change. + Potentially life-threatening
Inject into outer thigh 0.3 mg OR 0.15 mg
Antihistamine: Liquid Diphenhydramine (Benadryl®)
mg. To be given by mouth only if able to swallow.
This child has received instruction in the proper use of the Auto-injector: EpiPen® or Twinject® (circle one). It is my professional opinion that this student SHOULD be allowed to carry and use the auto-injector independently. The
child knows when to request antihistamine and has been advised to inform a responsible adult if the auto-injector is
It is my professional opinion that this student SHOULD NOT carry the auto-injector.
Health Care Provider Signature ______________________ Phone: ______________ Date ________
1. Call 911. State that an allergic reaction has been treated, and additional epinephrine may be needed.
2. Call parents/guardian to notify of reaction, treatment and student's health status.
3. Treat for shock. Prepare to do CPR.
4. Accompany student to ER if no parent/guardians are available.
This form is adapted from The Food Allergy Anaphylaxis Network, “Food Allergy Action Plan” & the Asthma and Allergy Foundation of America, AK Chapter A1 Side 2: To Be Completed by Parent/Guardian, Student and School
Allergy/Anaphylaxis Action Plan (continued) Student Name ________________________ D.O.B. _________
Each school will have 2 auto-injectors and liquid Diphenhydramine (Benadryl®) available during regular school hours.
If your child participates in before or after school activities, your child will need to have an auto-injector on their
□ I want this allergy plan implemented for my child; I want my child to carry an auto-injector and I agree
to release the school district and school personnel from all claims of liability if my child suffers any adverse reactions from self-administration of EpiPen. □ I want this plan implemented for my child and I do not want my child to self-administer epinephrine.
Your signature gives permission for the nurse to contact and receive additional information from your
health care provider regarding the allergic condition(s) and the prescribed medication.

Parent/Guardian Signature: __________________________Phone:_____________ Date:_________
Student Agreement:
□ I have been trained in the use of my auto-injector and allergy medication and understand the signs and
symptoms for which they are given;
□ I agree to carry my auto-injector with me at all times;
□ I will notify a responsible adult (teacher, nurse, coach, noon duty, etc.) IMMEDIATELY when my auto-
injector (epinephrine) is used;
□ I will not share my medication with other students or leave my auto-injector unattended;
□ I will not use my allergy medications for any other use than what it is prescribed for.
Student Signature: __________________________________________ Date ____________________
Approved by Nurse/Principal Signature: __________________________ Date __________________
PREVENTION: Avoidance of allergen is crucial to prevent anaphylaxis.
Critical components to prevent life threatening reactions: √ Indicates activity completed by school staff Encourage the use of Medic-Alert bracelets Notify nurse, teacher(s), front office and kitchen staff of known allergies Use non-latex gloves and eliminate powdered latex gloves in schools Ask parents to provide non-latex personal supplies for latex allergic students Post “Latex Reduced Environment” sign at entrance(s) of building Encourage a no-peanut zone in the school cafeteria This form is adapted from The Food Allergy Anaphylaxis Network, “Food Allergy Action Plan” & the Asthma and Allergy Foundation of America, AK Chapter A2


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