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

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?

Is your child able to administer their own medication?

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.

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.