FOOD ALLERGY & ANAPHYLAXIS EMERGENCY CARE PLAN
Child's Name
D.O.B.
Allergic to:
Child's Weight
Asthma?
Yes
Type option 2
Extremely reactive to the following foods:
Give epinephrine immediately...
for ANY symptoms if the allergen was likely eaten
if the allergen was definitely eaten, even if no symptoms are noted
MEDICATIONS/DOSES
Epinephrine Brand
Epinephrine Dose
0.15mg
0.3mg
Antihistamine Brand or Generic
Antihistamine Dose
Other (e.g. inhaler tronchodilator at wheezing)
PARENT/GUARDIAN AUTHORIZATION SIGNATURE
DATE
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: