MEDICAL FORM – SEVERE ALLERGY
School Year
20
- 20
Place
picture
here
MEDICAL FORM: SEVERE ALLERGY
(EMERGENCY CARE PLAN)
Name:__________________________________________ D.O.B.:
Allergy to: _________________________________________ Asthma:
Medication located:
Health Room
Classroom
Grade/Teacher: ______________
Yes (higher risk for a severe reaction),
FO R A NY O F T H E FO LL O W ING
NOTE: WHEN IN DOUBT, GIVE EPINEPHRINE.
SEVERE SYMPTOMS
IF checked, give epinephrine immediately if the allergen
was definitely eaten/stung, even if there are no
symptoms.
LUNG
HEART
THROAT
NO
Other:
MOUTH
Short of breath, Pale, blue, faint,
tight, hoarse,
Significant
weak pulse, dizzy trouble breathing/ swelling of the
wheezing,
swallowing
repetitive cough
tongue and/or lips
MILD SYMPTOMS
IF checked, give epinephrine immediately
for ANY symptoms, if the allergen was likely
eaten (or stung, if sting allergy).
MOUTH
NOSE
Itchy/runny nose, sneezing
itchy mouth
GUT
SKIN
O
c
SKIN
GUT
many hives over
body, widespread
redness
repetitive
vomiting or
severe diarrhea
Or a
n
combination
of mild &
severe symptoms
Feeling
something bad is from different
body areas.
about to happen,
anxiety, confusion
A few hives, mild itch
Mild nausea/discomfort
OTHER
NOTE: Do not depend on antihistamines or inhalers to treat a severe
reaction. Use Epinephrine.
1. GIVE ANTIHISTAMINES, IF
ORDERED (see medication box below)
2. Stay with student; contact parent/guardian for pickup
3. Watch student closely for changes. If symptoms
worsen, GIVE EPINEPHRINE.
MEDICATION(S)/DOSE
INJ ECT E PINEPHRINE IM M E DIATE LY.

Call 911. Request ambulance with epinephrine.

If additional medication is ordered (antihistamine and/or inhaler)
- administer it after the epinephrine.
Lay the student flat and raise legs. If breathing is difficult or they are
vomiting, let them sit up or lie on their side.
If symptoms do not improve, or symptoms return, more doses of
epinephrine can be given about 5 minutes or more after last dose.
Alert parent (or emergency contact if unable to reach parent).
Transport student to ER even if symptoms resolve. Student should
remain in ER for 4+ hours because symptoms may return.




Healthcare Provider Signature:
Healthcare Provider Printed Name:
Epinephrine Brand:
Epinephrine Dose:
0.1 5 mg IM
0.3 mg IM
Antihistamine Brand or Generic: ____________________________
Antihistamine Strength: __________________ Dose:
Other (e.g., inhaler if asthmatic):
_______________________________________________________
This student has demonstrated to the HCP that he or
she is capable of safely carrying and self-administering this
the above medication:
Yes
No
Date:
Phone: _______________ Fax:
*This order is for the current school year only. Medical orders (including care plans and medication forms) must be renewed prior to the start of each school year.
MEDICAL FORM – SEVERE ALLERGY
INDIVIDUAL CONSIDERATIONS:
Will this student ride the school bus to or from school?
Yes
No
• Transportation will be alerted to student's allergy.
• This student carries epinephrine on the bus:
Yes
No
• Epinephrine can be found in:
Backpack
On Person
Other _________________
• Please consider an extra supply of medication for before/after school activities
• Other (specify): ______________________________________________________________________
FIELP TRIP PROCEDURES: Epinephrine must accompany student during any off campus activity.
If student does not have the epinephrine on the day of the trip, he/she cannot attend.
• Student should remain with the teacher or parent/guardian during the entire field trip.
• Staff members on trip must be trained on epinephrine and student health care plan (plan must be taken).
• Other (specify):
FOR FOOD ALLERGY ONLY:
CLASSROOM
• Student is allowed to eat only the following foods:
Those in manufacturer's packaging with ingredients listed and determined allergen-safe by the
parent/guardian.
Middle school or high school student will be making his/her own decision.
Alternative snacks will be provided by parent/guardian to be kept in the classroom.
Parent/guardian should be advised of any planned parties as early as possible.
Classroom projects should be reviewed by the teaching staff to avoid specified allergens.
• Other (specify): _________________________________________________________________________
CAFETERIA
NO Restriction in seating arrangement.
Student will sit at a specified table.
• Cafeteria staff will be alerted to the student's allergy.
•Other:
PARENT/GUARDIAN Contact Information: (Please update your school office when contact information changes)
Name: _________________________ H: _______________ C: ______________ W: ____________
Name:
H:
C:
EMERGENCY CONTACTS (if unable to reach parent/guardian)
1.
Relationship:
2.
Relationship:
W:
Phone:
Phone:
• I request this medication to be given as ordered by the licensed health care provider.
• I give Health Services Staff permission to communicate with the medical office about this medication. I understand the
medication(s) will not necessarily be given by a school nurse (designated staff will be trained and supervised).
• Medical/Medication information may be shared with school staff working with my child and 911 staff, if they are called.
• All medication must come in its originally provided container with instructions as noted above by the licensed health care provider.
• I request and authorize my child to carry and/or self-administer their medication.
Yes
No
Parent/Guardian Signature -----------------
Date
School Nurse Signature
Date:
Principle Signature (for self-carry/administration)
Date:
A copy of the Health Care Plan will be kept in the substitute folder and given to all staff members who are
involved with the student.
Guidelines for Anaphylaxis *Adapted from Food Allergy Research & Education (FARE)
Revised Apr 2014