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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