Food Allergy Action Plan
Student’s
Name: __________________________ D.O.B:_________ Teacher:________________
Place Child’s
Picture Here
ALLERGY TO: _________________________________________________________
Asthmatic: *Yes □
No □
* higher risk for severe reaction
STEP 1: TREATMENT
Symptoms:
Give Checked Medication **:
(To be determined by physician authorizing treatment)
●
If a food allergen has been ingested, but no symptoms
Epinephrine
Antihistamine
●
Mouth
Itching, tingling, or swelling of lips, tongue, mouth
●
Skin
Hives, itchy rash, swelling of the face or extremities
Epinephrine
Epinephrine
Antihistamine
Antihistamine
●
Gut
Nausea, abdominal cramps, vomiting, diarrhea
Epinephrine
Antihistamine
●
Throat + Tightness if throat, hoarseness, hacking cough
●
Lung +
●
Heart+
Epinephrine
Epinephrine
Epinephrine
Antihistamine
Antihistamine
Antihistamine
●
Other +
●
If reaction is progressing (several of the above areas affected),
give
Epinephrine
Epinephrine
Antihistamine
Antihistamine
Shortness of breath, repetitive coughing, wheezing
Thready pulse, low blood pressure, fainting, pale,
blueness
____________________________________________
The severity of the symptoms can quickly change. + Potentially life-threatening.
DOSAGE
Epinephrine: inject intramuscularly (circle one): EpiPen® EpiPen® Jr. Twinject™ 0.3mg Twinject™ 0.15mg
Antihistamine: give Benadryl____________________________________________________________
medication/dose/route
Other: give____________________________________________________________________________
medication/dose/route
STEP 2: EMERGENCY CALLS
1. Call 911 (or Rescue Squad: __________). State that an allergic raction has been treated and additional
epinephrine may be needed.
2. Dr. Ziv Harish_________________ at___(201) 871-7475______
3. Emergency Contacts:
Name/Relationship
Phone Number(s)
a.__________________________
1.) __________________
2.) __________________
b.__________________________
1.) __________________
2.) __________________
c.____________________________
1.) __________________
2.) __________________
EVEN IF PARENT/GUARDIAN CANNOT BE REACHED, DO NOT HESITATE TO MEDICATE OR TAKE CHILD TO
MEDICAL FACILITY!
Parent/Guardian Signature _________________________________________ Date _____________
Doctor’s Signature _______________________________________________ Date _____________