Allergen Exposure Plan

Allergen Exposure Plan
Client Name:
Date:

MonthDayYear
Date
Your Allergies
Allergy #1
Type (food/medication/environmental):
Specific allergen:
Severity:

MildModerateSevere
Allergy #2
Type (food/medication/environmental):
Specific allergen:
Severity:

MildModerateSevere

Allergy #3
Type (food/medication/environmental):
Specific allergen:
Severity:

MildModerateSevere
Additional allergies:
What happens during a reaction?
Do you carry an EpiPen?

YesNo
Allergen Exposure Plan
Prevention precautions:
Items to avoid:
Emergency steps:

When to call 911:
Emergency contact name:
Emergency contact phone:
Doctor name:
Doctor phone:
EpiPen Policy:
Caregivers CANNOT administer an EpiPen. Caregivers may only retrieve the EpiPen for the client to self-administer.
Location of EpiPen:
Should be Empty: