MCILWRAITH STATE SCHOOL
Contacts
Form C - Allergic Reactions / Anaphylaxis Management Plan
Name
School
Parents / Caregivers Names
Home Telephone
Allergy / Anaphylaxis History
Name of Doctor:
Ambulance / Emergency Contact:
Date of Birth
Year Level
Work Telephone
Phone
What may trigger an allergic
reaction?
(food, drugs, pollen, insect bites,
etc.)
What are the warning signs and
symptoms of the allergic
reaction?
(rash, swelling, pain, etc.)
Is the reaction local (affecting
only a small area) or general
(affecting different parts of the
body)?
In the past, has a reaction resulted in the obstruction of airways, or an
anaphylactic reaction requiring the administration of Adrenaline?
Yes
Do you take any medication to relieve or treat the allergic reaction?
Yes
During the allergic reaction
Medication
Dosage and details of administration (when and how medication is given)
No
No
Emergency Action
After the allergic reaction
Do you carry an Adrenaline Injector (Epipen / Minijet syringe)?
Yes
No
Detailed plan of first aid treatment provided by medical practitioner is attached
Or; Standard allergic reaction first aid plan as below should be followed (please tick steps required)
Step 1:
Remove (if possible) source of reaction; [ eg: remove bee stingers by scraping them out of the skin,
remove food from contact with skin or from mouth and wash mouth out – do NOT induce vomiting]
Step 2:
Step 3:
Step 4:
Step 5:
Step 6:
Step 7:
Monitor site for swelling, monitor pulse and other vital signs during whole period of treatment.
Apply ice to site.
Administer anti-histamine (if prescribed).
Arrange for collection by parent / carer.
Administer Adrenaline - epipen – (if prescribed) - if anaphylaxis occurs.
Call for ambulance treatment and possible transportation.
I declare that the information on this form is complete and correct and is based on advice provided by a
medical practitioner. I further request that the medication as specified on this form be administered, or
assistance be provided in the management of the medication, in accordance with the instructions
provided.
Signature: ………………………………………….…………
Relationship to student: ...……………….
Print Name: …………………………………………………..
Date: ……/……/……
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