FOOD ALLERGY ACTION PLAN
Child’s Name ____________
_______ D.O.B.
Place child’s
photo here
Room
ALLERGY TO
Asthmatic (High risk for severe reaction)
Yes
No
SIGNS OF AN ALLERGIC REACTION
SYMPTOMS
SYSTEMS
Please indicate which symptoms will likely be present during an allergic reaction.
Mouth
Throat
Skin
Stomach
Itching and swelling of the lips, tongue, or mouth
Itching and/or sense of tightness in throat; hoarseness, and hacking cough
Hives, itchy rash, and/or swelling about the face or extremities
Nausea, abdominal cramps, vomiting, and/or diarrhea
Lungs
Heart
Shortness of breath, repetitive coughing, and/or wheezing
Thready/weak pulse, loss of consciousness
ACTION FOR MINOR REACTION
1. If only symptom(s) are:
, give
medication/dose/route
.
Then call:
2. Mother ___________________________, Father ____________________________, or emergency contacts.
3. Dr.
at
.
If condition does not improve within 10 minutes, follow steps for Major Reaction below.
ACTION FOR MAJOR REACTION
1. If ingestion is suspected and/or symptom(s) are:
,
give
IMMEDIATELY!
medication/dose/route
Then call:
2. Rescue Squad (ask for advanced life support)
3. Mother___________________________, Father ____________________________, or emergency contacts.
4. Dr.
at
.
DO NOT HESITATE TO CALL RESCUE SQUAD!
By signing this form, I agree to have this food allergy action plan posted in food preparation areas and/or classrooms.
Parent’s Signature
LilyPad Learning Center
06/2008
Date
Doctor’s Signature
LilyPad Learning Center
06/2008
Date