New London School District – Health Services FOOD ALLERGY Care Plan Student's Name Grade Parent/Guardian Phone # Work Physician School Home # Phone # Asthmatic * Yes (* =High risk for severe reaction) Food allergy: No Reaction: Child MUST sit at allergy free table: yes no Additional health problems besides anaphylaxis: PLEASE CHECK ALL SIGNS OF AN ALLERGIC REACTION INCLUDE: Mouth Throat* Skin Gut Lung* Heart* itching & swelling of the lips, tongue, or mouth itching and/or a sense of tightness in the throat, hoarseness, and hacking cough hives, itching rash, and/or swelling about the face or extremities nausea, abdominal cramps, vomiting, and/or diarrhea shortness of breath, repetitive coughing, and/or wheezing "thready" pulse, "passing-out" Please tell us what you want us to do in case of an allergic reaction at school. Only a few symptoms may be present. Severity of symptoms can change quickly. *Some symptoms can be life-threatening. ACT FAST! Emergency Action Steps - DO NOT HESITATE TO GIVE EPINEPHRINE! 1. Give 1st and monitor for symptoms of Anaphylaxis. 2. Inject epinephrine in thigh using (check one) if these symptoms occur: EpiPen Jr (0.15 mg) Specify others: EpiPen (0.3 mg) Epinephrine Injection Antihistamine Inhaler Other: *IMPORTANT: ASTHMA INHALERS AND/OR ANTIHISTAMINES CAN’T BE DEPENDED ON IN ANAPHYLAXIS. 3. Call 911 or rescue squad before calling parent or emergency contact: Parent contact: home work cell Emergency contact #1: home work cell Additional comments ***If medication is needed, a supply must be kept at school for your child to participate in field trips/extracurricular activities. Parent/Guardian Electronic Signature (initials): Date: Your typed initials will serve as your signature Physician Signature: _________________________________________Date:__________________________ School Nurse Signature: ________________________________________Date of review_________________ Upon completing this form, please print the form and hand it in at registration OR save it and email the form to Susan Resch, RN, BSN at firstname.lastname@example.org. If medication is needed for this concern, you must also fill out a medication consent form. Thank you.