Food Allergy Action Plan

**To be determined by physician authorizing treatment*

	**Epinepherine	**Antihistimine
If Allergan has been ingested but no symptoms
Mouth: Itching, tingling or swelling of lips, tongue, mouth
Skin: Hives, itchy rash, swelling of the face or extremities
Gut: Nausea, abdominal cramps, vomiting, diarrhea
Throat*: Tightening of throat, hoarseness, hacking cough
Lung*: Shortness of breath, repetitive coughing, wheezing
Heart*: Weak or thready pulse, low blood pressure, fainting, pale, blueness
If reaction is progressing (several of the above areas affective), give:

* Potentially life-threatening. The severity of symptoms can quickly change.
DOSAGE
Epinephrine: Inject Intramuscularly (select one)

EpiPenEpiPen Jr.Twinject 0.3mgTwinject 0.15mg
Antihistimine:
Other:
IMPORTANT

Asthma inhalers and/or antihistimines cannot be depended on to replace epinephrine in anaphylaxis
STEP 2

EMERGENCY CALLS
- Call 911 (State that an allergic reaction has been treated, and additional epinephrine may be needed)
- Call parent/guardian or physician
Parent /Guardian Name*

Parent's/Guardian's First NameParent's/Guardian's Last Name
Parent/Guardian Home Phone*
Please enter a valid phone number.
Parent/Guardian Cell Phone*
Please enter a valid phone number.
Parent/Guardian Email*
example@example.com
Physician's Name*

First NameLast Name
Physician's Phone*
Please enter a valid phone number.
EMERGENCY CONTACTS
Contact 1*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*
Contact 2

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Contact 3

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
EVEN IF PARENT/GUARDIAN CANNOT BE REACHED, DO NOT HESITATE TO MEDICATE OR TAKE CHILD TO MEDICAL FACILITY.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Physicians Signature

Clear
Date

MonthDayYear
Please verify that you are human*
Should be Empty:

STUDENT INFORMATION