INDIVIDUALIZED EPINEPHRINE EMERGENCY ACTION PLAN
Student’s Name:__________________________DOB:_________GRADE:________
ALLERGY TO:________________________________________________________
ASTHMATIC
Yes *_____
NO_____
*High risk for severe reaction
SIGNS OF AN ALLERGIC REACTION
(Highlight or circle symptoms appropriate to child)
Systems:
 Mouth
 Throat
 Skin
 Gut
 Lung *
 Heart *
Place
Child’s
Picture
Here
Symptoms:
Itching and swelling of the lips, tongue, or mouth
Itching and/or a sense of tightness in the throat, hoarseness, and hacking cough
Hives, itchy rash and/or swelling about the face or extremities
Nausea, vomiting, abdominal cramps and/or diarrhea
Shortness of breath, repetitive coughing and/or wheezing
Thready pulse, passing out
The severity of symptoms can quickly change. *All above symptoms can potentially progress
to a life threatening situation.
1. If an allergic reaction is suspected, give: _____0.3mg Epi-Pen IM or _____0.15mg Epi-pen Junior IM
and Benadryl __________PO immediately.
dosage
2. Call Emergency Medical Services: 9-1-1
3. Call School Nurse if not present.
4. Call: Mother______________________________________________________________________
(home)
(work)
(cell)
Call: Father_______________________________________________________________________
(home)
(work)
(cell)
or emergency contacts (listed on other side)
5. Possible side effects of Epi-Pen: Palpitations, tachycardia (rapid heart beat), sweating, nausea,
vomiting, breathing difficulties, pale skin color, dizziness, weakness, tremor, headache, anxiety
apprehension, and nervousness.
6. Stay with child until emergency help arrives – position child on left side.
DO NOT HESITATE TO ADMINISTER MEDICATION OR CALL EMERGENCY MEDICAL
SERVICES, EVEN IF PARENTS CANNOT BE REACHED!
Physician Signature:____________________________________________Date:_______________________
 All students must be transported to the hospital by Emergency Medical Services (EMS) after receiving
Epi-pen.
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I give permission for the school nurse (or appropriately trained school personnel) to administer Epi-Pen and
share information as deemed necessary for my child’s health and safety.
I give permission for my son/daughter to self-administer their Epi-Pen as prescribed by his/her physician.
______Yes
______No
Parent Signautre:______________________________Date:_____________________________
Nurse Signature:______________________________Date:_____________________________
Epi-Pen Location(s):
Expiration Date(s):
__________________________________________________________________________________________
__________________________________________________________________________________________
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