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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