FOOD ALLERGY ITALIA
associazione italiana allergie alimentari
Registro Associazioni di Promozione Sociale del Veneto N. PSPD0064
FOOD ALLERGY AND ANAPHYLAXIS:
ACTION PLAN IN CASE OF EMERGENCY
AT SCHOOL (school year
)
Name______________________________________________________
Surname____________________________________________________
Patient Photo
Date of Birth__________________________________________________
Class_______________________________________________________
ALLERGIC TO:
 Cereals containing gluten
 Peanuts
 Shellfish
 Soya
 Egg
 Milk
 Fish
 Treenuts
Others
PREVIOUS ANAPHYLACTIC REACTION:  YES  NO
ASTHMA:  YES  NO
}
high risk
of developing
a severe
allergic reaction
SYMPTOMS OF ALLERGIC REACTION:
(at the simultaneous appearance of multiple symptoms proceed with the pharmacological intervention plan)
 MOUTH: swelling and itching of the lips and throat.
 THROAT: itching, irritating barking cough, hoarse voice.
 SKIN: localized or diffused hives or rash , swelling of the face or extremities.
 DIGESTIVE SYSTEM: nausea, abdominal cramp pain, repeated vomiting and/or diarrhea.
 RESPIRATORY SYSTEM: irritating barking cough, wheezing, breathing difficulty.
 CIRCULATORY SYSTEM: collapse.
 NEUROLOGICAL SYSTEM: lifelessness, feeling down, loss of consciousness.
PHARMACOLOGICAL INTERVENTION PLAN
COPYRIGHT © BY FOOD ALLERGY ITALIA 2004 – 2014
Tutti i diritti riservati ®. Il contenuto di questa pubblicazione non può essere riprodotto, in tutto od in parte, archiviato o diffuso pubblicamente, per via elettronica od a mezzo stampa, fotocopia, microfilm
o tramite qualsiasi altro mezzo, senza l’espressa autorizzazione scritta di FOOD ALLERGY ITALIA.
Registro Associazioni di Promozione Sociale del Comune di Padova N. 1275
N.B. The student’s lifesaving kit can be found
1. If symptoms are: ITCHING OF THROAT, SWOLLEN TONGUE AND LIPS, HIVES OR
RASH, NAUSEA, ABDOMINAL CRAMP PAINS
 Administer: ANTIHISTAMINE commercial name
dosage
expiry date
(to be kept at room temperature and away from light)
 ANTIHISTAMINE ADMINISTERED AT: Date
Time
 Administer: BRONCHODILATOR commercial name
dosage
expiry date
(to be kept at room temperature and away from light)
 BRONCHODILATOR ADMINISTERED AT: Date
Time
35121 PADOVA – Piazza De Gasperi, 45/A – www.foodallergyitalia.org – info@foodallergyitalia.org –
+39 3402391230 – +39 0498761155
In cooperation with the Referral Centre for Food Allergy, Veneto Region, Padua General University Hospital, Padua, Italy
FOOD ALLERGY ITALIA
associazione italiana allergie alimentari
ii
Registro Associazioni di Promozione Sociale del Veneto N. PSPD0064
Registro Associazioni di Promozione Sociale del Comune di Padova N. 1275
2. If symptoms progress (10-15 mins): HIVES WITH SWELLING OF THE FACE AND/OR HOARSE VOICE AND /OR BREATHING DIFFFICULTY AND /OR COLLAPSE
mg
(to be kept at room temperature and away from light)
INRUCTIONS FOR USE OF SELF-INJECTABLE EPINEPHRINE
2
1
1. Remove the colored cap.
3
2. Place the pen tip on the outer
thigh.
4
The two self-injectors available on the Italian market:
- Jext (on the left);
- Fastjekt (on the right).
3. Press firmly until you hear a click
of activation. Leave in position for
10 seconds.
4. Remove the pen.
 leave the person where he/she is and never alone, avoiding to keep him/her in upright position
 if the person is conscious put him/her in antishock position, raising the legs up to facilitate the flow of blood to
the head and heart.
If the person has breathing difficulties (asthma) raise his/
her upper body off the ground
 if the person is unconscious, put he/she in recovery position according to the rules of first aid
 EPINEPHRINE ADMINISTERED AT: Date
Time
 Call 118 and inform:
MOTHER
tel.
FATHER
tel.
MEDICAL REFERENCE
tel.
OTHERS
tel.
SCHOOL CONTACT
HAND OVER THE ADMINISTERED EPINEPHRINE TO THE FIRST AID PERSONNEL OR TO THE EMERGENCY ROOM STAFF WHERE THE INDIVIDUAL HAS BEEN TAKEN FOR SUBSEQUENT OBSERVATION.
PARENTS’ SIGNATURES:
ATTENDING PHYSICIAN’S SIGNATURE:
Date and Place:
35121 PADOVA – Piazza De Gasperi, 45/A – www.foodallergyitalia.org – info@foodallergyitalia.org –
+39 3402391230 – +39 0498761155
In cooperation with the Referral Centre for Food Allergy, Veneto Region, Padua General University Hospital, Padua, Italy
COPYRIGHT © BY FOOD ALLERGY ITALIA 2004 – 2014
Tutti i diritti riservati ®. Il contenuto di questa pubblicazione non può essere riprodotto, in tutto od in parte, archiviato o diffuso pubblicamente, per via elettronica od a mezzo stampa, fotocopia, microfilm
o tramite qualsiasi altro mezzo, senza l’espressa autorizzazione scritta di FOOD ALLERGY ITALIA.
 Administer: SELF-INJECTABLE EPINEPHRINE phial
commercial name
expiry date