Sampson County
left-34290000 Allergy/Anaphylaxis Emergency Plan Separate form required for each allergy LOCATION OF MEDICATION(S): ____________________________________________________Student:Parent/Guardian:School:Home Phone:Teacher: Grade:Work Phone:Bus Driver: Bus Number:Cell Phone:ALLERGIC TO _______________________________________________________________________________________ Example: latex, foods (name each food) insects (name each insect) SYMPTOMS DURING AN ALLERGIC REACTION_____________________________________________________________1. HAS YOUR CHILD BEEN TO A HEALTH CARE PRACTITIONER, EMERGENCY ROOM, OR HAD TO USE EMERGENCY MEDICATION DUE TO AN ALLERGIC REACTION? YES NO PLEASE EXPLAIN ________________________________2. IS IT SAFE FOR YOUR CHILD TO SIT WITH OTHERS WHO ARE EATING THE ABOVE LISTED ALLERGEN(S) (IF APPLICABLE) YES NO***This section must be completed by a health care practitioner if medication(s) is/are required at school***For no symptoms (severe allergy; give even if no symptoms)Epinephrine AntihistamineMouth - tingling, itching, swelling of lips, tongue, mouthEpinephrine AntihistamineSkin - hives, itchy rash, swelling of face, arms, legsEpinephrine AntihistamineGut - nausea, abdominal cramps, vomiting, diarrheaEpinephrine Antihistamine*Throat - tightening of throat, hoarseness, hacking coughEpinephrine Antihistamine*Lungs-shortness of breath, repetitive coughing, wheezingEpinephrine Antihistamine*Heart - weak, uneven pulse, low blood pressure, fainting,pale, blueEpinephrine Antihistamine*Very Serious, Call 911 immediately*If antihistamine is given, call parent/guardian*DO NOT HESITATE TO CALL 911*DO NOT HESITATE TO GIVE MEDICATION*If epinephrine auto-injector is used, call 911** MUST BE SIGNED BY HEALTH CARE PRACTITIONER ONLY IF MEDICATION(S) IS/ARE REQUIRED AT SCHOOL**__________________________________ __________Health Care Practitioner Signature DatePLEASE NOTE: If medication and/or an EpiPen are to be taken or kept at school, a medication authorization form must be completed by a parent and health care practitioner and kept at the school. A new form(s) is/are to be completed every school year. I do not wish to have an allergy care plan in place for my child. I understand that my child will be treated in an emergency situation by calling 911 and parent/emergency contact.__________________________________ ___________Parent Signature Date__________________________________ ___________School Nurse Signature Date Rev. 4/20 School Nurses ................
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