Student Name___________________________ DOB ...
Student Name___________________________ DOB_________________ Date____________
Height___________________ Weight_______________________ BP___________________
ALLERGIES____________________________________________________________________
ASTHMA*Yes____No____ (*Higher risk for anaphylaxis: Inhalers DO NOT prevent anaphylaxis)
Is the student a known reactor? Yes____ No____ Received Epi-Pen in the past Yes____ No____
EMERGENCY TREATMENT
SYMPTOMS: Give Checked Medication as per MD
|Exposure to allergen, but asymptomatic |Epinephrine | |Antihistamine | |
|Mouth – tingling, itching, swelling lips, tongue, mouth |Epinephrine | |Antihistamine | |
|Skin – hives, itchy rash, swelling of face/extremities |Epinephrine | |Antihistamine | |
|Gut – nausea, abdominal cramps, vomiting, diarrhea |Epinephrine | |Antihistamine | |
|Throat** - tightening of throat, hoarseness, cough |Epinephrine | |Antihistamine | |
|Lungs** - SOB, repetitive cough, wheezing |Epinephrine | |Antihistamine | |
|Heart**-weak/thready pulse, low BP, pallor, cyanosis |Epinephrine | |Antihistamine | |
**Potentially life-threatening. Symptoms can exacerbate quickly.
Other: May carry 1 dose antihistamine for self administration – Yes________ No________
(prior to getting epinephrine) Name and dose of medication: ___________________________
If reaction affects more than one of the above areas give: Epinephrine_____ Antihistamine_____
Medications:
Epinephrine: Inject into thigh muscle, pressure for 15 seconds. Circle appropriate medication:
Auvi-Q 0.15mg Auvi-Q 0.3mg Epi-Pen Epi-Pen Jr. Twinject 0.15mg Twinject 0.15mg
Antihistamine: __________________________________________________________________
(Medication/Dose/Route)
Other Treatments: ______________________________________________________________
In the event there is no nurse available and there is a non medical delegate do you give permission for the antihistamine and/or other medications to be omitted? This would mean ONLY Epinephrine would be administered at the time of the incident.
Yes_____ Give Epi-Pen first and omit the other medication(s).
No______ DO NOT omit an of the medications before giving the Epi-Pen.
911 Must be initiated if epinephrine is administered.
_________________________________________ _____________________ ______________
Physician Signature Phone # Date
__________________________________ ____________
Parent Signature & Phone# Date
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