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Allergy Action Plan

Required

Student:required
First Name
Last Name
Schoolrequired
Asthmatic:required*High risk for severe reaction
*High risk for severe reaction
SIGNS OF AN ALLERGIC REACTION - Systems: Symptoms:
•MOUTH itching & swelling of the lips, tongue, or mouth
•THROAT* itching and/or a sense of tightness in the throat, hoarseness, and hacking cough
•SKIN hives, itchy rash, and/or swelling about the face or extremities
•GUT nausea, abdominal cramps, vomiting, and/or diarrhea
•LUNG* shortness of breath, repetitive coughing, and/or wheezing
•HEART* “thready” pulse, “passing-out” The severity of symptoms can quickly change. *All above symptoms can potentially progress to a life threatening situation.
ACTION FOR MINOR REACTION
1. If the only symptom(s) are: MILD - hives, itchy rash or itchy eyes
2. Give Benadryl: 25mg PO, may repeat in 1 hour if symptoms have not resolved medication/dose/route

Notify:

Parent/Guardian:requiredIf condition worsens, follow steps for Major Reaction below.
First Name
Last Name
If condition worsens, follow steps for Major Reaction below.
ACTION FOR MAJOR REACTION
1. If ingestion is suspected and/or symptom(s) are: Moderate to Severe - Multi-system or respiratory involvement
2. IMMEDIATELY administer EPIPEN: 0.15mg /0.3mg Epinephrine IM to outer thigh medication/ CIRCLE ONE DOSE/route 
→ Student may self carry EPIPEN and self administer medication as per MD orders
(High School & Middle School ONLY. Elementary students may not self carry).
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Then call: 1. 911 (ask for advanced life support and EPIPEN)
2. Parent/Guardian: required
First Name
Last Name
DO NOT HESITATE TO CALL 911!
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