Nash-Rocky Mount Public Schools
Allergy/Anaphylaxis EAP Medication Authorization
rStudent Health Services
*healthcare provider signature required
Student
Date of Birth
Weight
School
Teacher
Grade
Parent/Legal Guardian
Contact #1
#2
Allergies, list ____________________________________________
Name of healthcare provider
Asthma __Y __N Inhaler __Y __N
Office #
Severely allergic/reactive to the following:
Therefore:  If checked, give epinephrine immediately for any symptoms if the allergen was likely eaten.
 If checked, give epinephrine immediately if the allergen was definitely eaten, even if no symptoms noted.
For any of the following severe symptoms of anaphylaxis:
Lungs: Shortness of breath, wheezing, repetitive
coughing/sneezing, chest tightness
Throat: Tightness/closure, hoarse/scratchy, trouble
breathing/swallowing, drooling, itching
Mouth: Swollen tongue/lips, slurred speech, blue lips
Heart: Pale, blue, faint, weak pulse, dizzy, passing out
Skin:
Swelling/severe itching, many/large hives,
widespread redness
Gut:
Vomiting 2 or more times, severe
diarrhea/cramps
Other: Anxiety, confusion, feeling of doom
 A combination of bodily symptoms may occur.
 Only a few symptoms may be present.
 Severity of symptoms can change quickly.
 Some symptoms can be life threatening.
Act fast! Do this:
1. Inject epinephrine in thigh immediately--no hesitation.
2. Call 911.
3. Tell them the child is having anaphylaxis and may need
epinephrine when they arrive.
4. May need to give additional meds after epinephrine:
 Antihistamine – e.g., Benadryl
 Inhaler if wheezing – Bronchodilator
5. Lay the person flat, raise legs, and keep warm. If
breathing is difficult or if vomiting, lie on side or sit up.
6. If symptoms do not improve or symptoms return and 5
minutes or more have passed since last dose, give 2nd
dose of epinephrine.
7. Transport to ER, even if symptoms resolve.
8. Alert parent/legal guardian.
For mild symptoms of anaphylaxis:
Do this:
1. For mild symptoms from more than one system area,
give epinephrine.
2. For mild symptoms from a single system area:
 Give antihistamine, if ordered by provider.
 Stay with the person.
 Alert parent/legal guardian.
 Watch closely for changes in symptoms; if
symptoms worsen, give epinephrine.
Nose:
Mouth:
Skin:
Gut:
Itchy or runny, sneezing
Itchy
Mild itch, a few hives
Mild nausea/discomfort
Medication Administration Authorization - to be completed by Healthcare Provider
Epinephrine
Antihistamine
Epinephrine Dose  0.15 mg IM  0.30 mg IM
Antihistamine Dose
Other—e.g., inhaler if wheezing
Medication Dose
This student:  Has been instructed in and  Demonstrates proper use/care of the medication(s) listed above.
This student:  Should be allowed to carry and self-administer this medication at school.
Healthcare Provider Signature
Date
Parent/Legal Guardian Signature
Date
School Nurse Signature
Date
Document medical alert in PowerSchool and Permanent Health Record. File original in IHR. Copies to designated staff w/medication record/logs.
Rev. 9/1/2015