Allergy Action Plan

Allergy Action Plan
Name of Parent/Carer filling out this form*

First NameLast Name
Name of Child*

First NameLast Name
Please detail all of your child's allergies*
Are your child's allergies*

AirbourneContactIngested
What are the signs and symptoms your child is having an allergic reaction? *
Please detail emergency treatment or medication to be given to your child if they suffer an allergic reaction, including the dose and frequency.*
Will your child inform us when they need their medication?*

YesNo
Is your child able to administer their own medication?*

YesNo
If your child takes antihistamines for an allergic reaction, please confirm you will leave a supply in the medical room in case they are needed.*

YesNo
If applicable, please ensure that your child carries their auto-injector pen with them at all times.

Please ensure you supply the medical room with a spare auto-injector pen.
Should be Empty: