Food Allergy Action Plan - Lily Pad Learning Center
FOOD ALLERGY ACTION PLAN
Child’s Name ____________ _______ D.O.B. Room
ALLERGY TO
Asthmatic (High risk for severe reaction) Yes No
SIGNS OF AN ALLERGIC REACTION
|SYSTEMS |SYMPTOMS |
| |Please indicate which symptoms will likely be present during an allergic reaction. |
|Mouth |Itching and swelling of the lips, tongue, or mouth |
|Throat |Itching and/or sense of tightness in throat; hoarseness, and hacking cough |
|Skin |Hives, itchy rash, and/or swelling about the face or extremities |
|Stomach |Nausea, abdominal cramps, vomiting, and/or diarrhea |
|Lungs |Shortness of breath, repetitive coughing, and/or wheezing |
|Heart |Thready/weak pulse, loss of consciousness |
ACTION FOR MINOR REACTION
1. If only symptom(s) are: , give
medication/dose/route
.
Then call:
2. Mother ___________________________, Father ____________________________, or emergency contacts.
3. Dr. at .
If condition does not improve within 10 minutes, follow steps for Major Reaction below.
ACTION FOR MAJOR REACTION
1. If ingestion is suspected and/or symptom(s) are: ,
give IMMEDIATELY!
medication/dose/route
Then call:
2. Rescue Squad (ask for advanced life support)
3. Mother___________________________, Father ____________________________, or emergency contacts.
4. Dr. at .
DO NOT HESITATE TO CALL RESCUE SQUAD!
By signing this form, I agree to have this food allergy action plan posted in food preparation areas and/or classrooms.
Parent’s Signature Date
Doctor’s Signature Date
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Place child’s
photo here
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