Appendix 2
Page 1 of 8
Form 8(a): Individual Health Care Plan
Severe Allergies
Pupil’s name:
Date of birth:
CHI:
Address:
Insert photograph
of pupil
School:
This Plan should be completed by the pupil’s parent/carer and approved by the hospital consultant/
specialist nurse/GP.
The parent/carer is responsible for obtaining a medical practitioner’s signature.
Once completed, the parent/carer is responsible for taking a copy of this Individual Health Care Plan
to all relevant hospital/GP appointments for updating
Appendix 2
Page 2 of 8
Form 8(a): Individual Health Care Plan
Severe Allergies
Parent/Carer Contact 1
Parent/Carer Contact 2
Name:
Name:
Relationship to pupil:
Relationship to pupil:
Address:
Address:
 Home:
 Home:
 Work:
 Work:
 Mobile:
 Mobile:
Hospital/Clinic Contact
General Practitioner
Name:
Name:
Address:
Address:


Other Relevant Contact(s)
Name:
Name:
Address:
Address:


Appendix 2
Page 3 of 8
Form 8(a): Individual Health Care Plan
Severe Allergies
Details of Medical Condition
This pupil is allergic to:
Details of Symptoms:
The pupil may present with some of the following symptoms:
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itching
red blotchy rash
tingling/burning sensation in mouth
tingling/burning sensation in lips
swelling of lips
swelling of eyes
swelling of face
swelling round sting
increased rate of breathing
behaviour change, less responsive or confused
collapse
Details of medication:
Medication
Dose
Comment
Antihistamine
As per action flow chart. Repeat if vomited within 30
minutes. (Continue 4 hourly for 24 hours)
(Name of medication)
Ventolin (Salbutamol) Inhaler
As per action flow chart. 2-10 puffs via spacer, 2
puffs initially then 1 puff per minute.
Adrenaline Pen
As per action flow chart.
Parent/carer, please consult your GP when your
child’s weight has reached 30kg as they will require
the adult adrenaline pen.
Details of emergency care: Follow instructions as per flow chart attached
Appendix 2
Page 4 of 8
Form 8(a): Individual Health Care Plan
Severe Allergies
School Management of Severe Allergies (Anaphylaxis)
All school staff, supply teachers, visiting teachers and support staff should be made aware of severe
allergies and anaphylaxis and the emergency care procedures.
Involved staff will know about the Individual Health Care Plan.
In primary schools, one adrenaline pen will be kept in a zipped ‘poly pocket’, with the Emergency
Care Flow Diagram, in the pupil’s classroom. Another adrenaline pen will be kept, with an
Emergency Care Flow Diagram in a central, easily accessible place.
In secondary schools, the pupil will carry one adrenaline pen with another adrenaline pen kept in a
central, easily accessible place with an Emergency Care Flow Diagram. Emergency Care Flow
Diagrams should also be kept in the register folder in each classroom
It is the responsibility of the parent/carer to ensure that:
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medication is supplied to the school.
the medication is ‘in date’.
the medication is replaced as necessary.
the medication is collected at the end of each summer term.
all medication has the original pharmacy label attached stating: the pupil’s name, date of
birth and dose.
The class register should be clearly marked to indicate pupils with severe allergies so that when a
supply teacher takes a class she/he is aware of any pupils with severe allergies in that class.
Consideration of a pupil’s allergies will be made with regard to classes to be attended, e.g. food
preparation or use of certain materials in science.
Appendix 2
Page 5 of 8
Form 8(a): Individual Health Care Plan
Severe Allergies
Symptom and Action Flowchart for Severe Allergic Reaction (Anaphylaxis)
Using an Adrenaline Pen
Insert photograph
Pupil’s name:
of pupil
Date of birth:
Refer to Individual Health Care Plan and medication container for
dosages.
Severe Reaction
Mild/Moderate Reaction
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Swollen lips
Flushed, itchy, blotch skin
Abdominal pain and nausea
Swelling round eyes
Fast breathing
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Swollen tongue
Hoarse voice, difficulty swallowing
Cough, difficulty breathing, noisy,
laboured breathing
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Change in colour
Feeling faint
Deteriorating consciousness
Collapse
Lie pupil down and raise pupil’s feet.
Give Antihistamine Dose: as
stated on pharmacy label
Administer Adrenaline Pen
 Hold Adrenaline Pen firmly
 Remove outer safety cap
 Hold the other end (non-safety cap
end) of Adrenaline Pen 2 cm from
the upper outer thigh
 Jab the Adrenaline Pen into the leg
until you hear it click
 Hold the Adrenaline Pen firmly in
place for 10 seconds
 Remove Adrenaline Pen from leg
 Rub leg
If asthmatic, give reliever via
spacer (2 puffs).
Another 8 puffs, 1 puff per
minute, can be given.
Contact parent/carer to inform
them that their child has had an
allergic reaction
Supervise closely.
If condition worsens to severe
reaction:
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Dial 999
Follow instructions from ambulance control
Stay with child
If no improvement in breathing or alertness
after 5 minutes, give second Adrenaline Pen
Contact parents
Give Adrenaline Pen to ambulance staff
Appendix 2
Page 6 of 8
Form 8(a): Individual Health Care Plan
Severe Allergies
Symptom and Action Flowchart for Severe Allergic Reaction (Anaphylaxis)
WITHOUT Using Adrenaline Pen
Pupil’s name:
Date of birth:
Refer to Individual Health Care Plan and medication container for
dosages.
Insert photograph
of pupil
Mild/Moderate Reaction
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Swollen lips
Flushed, itchy, blotch skin
Abdominal pain and nausea
Swelling round eyes
Fast breathing
Severe Reaction
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Give Antihistamine Dose: as
stated on pharmacy label
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If asthmatic, give reliever via
spacer (2 puffs).
Another 8 puffs, 1 puff per
minute, can be given.
Swollen tongue
Hoarse voice, difficulty swallowing
Cough, difficulty breathing, noisy,
laboured breathing
Change in colour, pale, clammy
Feeling faint
Deteriorating consciousness
Collapse
Lie pupil down and raise pupil’s feet.
Contact parent/carer to inform
them that their child has had an
allergic reaction.
Supervise closely.
If condition worsens to severe
reaction:
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Dial 999
Follow instructions from ambulance control
Contact parents
Stay with child
Appendix 2
Page 7 of 8
Form 8(a): Individual Health Care Plan
Severe Allergies
Agreement to Individual Health Care Plan
This Plan was completed on
and its contents agreed by the undersigned.
Parent/carer
I wish my child to have the medication/care detailed in this plan and I accept that the emergency
services will be summoned, as required, in the event that the school staff are unable to administer
the plan at any time where appropriate.
Name of parent/carer:
Signature:
Date:
Pupil (if appropriate)
Name of pupil:
Signature:
Date:
Medical practitioner
Name of medical practitioner:
Signature:
Date:
Date of next planned review:
(no later than 12 months from date of initial completion)
For completion by school:
CONFIRMATION OF THE SCHOOL’S AGREEMENT
I agree to the procedures detailed in this plan being administered in school. In the event that these
procedures cannot be implemented at any time the school will follow the advice received from the
health professionals in summoning the emergency services where appropriate.
Name of Head Teacher/designated person:
Signature:
Copy to be given to parent/carer.
Date:
Appendix 2
Page 8 of 8
Form 8(a): Individual Health Care Plan
Severe Allergies
Review Agreement Statement by Parent/Carer
Pupil’s name:
Date of birth:
I confirm that the existing Individual Health Care Plan for my child continues to reflect the current
needs of my child.
I agree therefore that the review date stated on the Plan remains applicable.
I will inform the school if my child’s needs change prior to the agreed review date.
Name of parent/carer:
Signature:
Copy to be given to parent/carer.
Date: