FOOD ALLERGY ACTION PLAN
Student’s Name: _____________________________ D.O.B.___________________
ALLERGY TO: _______________________________________________________ Child’s
A special table for lunch/snacks is requested. ALLERGIC REACTION TREATMENT for ALLERGIC REACTION Any of these symptoms can represent an allergic reaction: 1. Injectable Epinephrine (check one) Mouth: itching and swelling of the lips, tongue or mouth Skin: hives, swelling of the face or extremities
❑ Twinject™ 0.3mg ❑ Twinject™ 0.15mg
Gut: nausea, abdominal pain, cramps, vomiting, diarrhea 2. Antihistamine Throat: tightening of throat, hoarsess, hacking cough Lungs: shortness of breath, repetitive cough, wheezing Heart: weak or thready pulse,low blood pressure, fainting, 3. Other ___________________________ 4. Call 911. State that an allergic reaction has Other: _____________________________________________
occured and epinephrine has been given. 5. Call Emergency Contacts (see below) SUSPICIOUS ALLERGIC REACTION TREATMENT for SUSPICIOUS REACTION 1. Antihistamine Symptoms: itchy rash or a few hives
❑ Benadryl ______________❑ Other _________________
2. Call Emergency Contacts (see below) Emergency Contacts: 1. Name/Relationship Phone Number(s) Phone Number(s)
a. _______________________________________ ________________________ _______________________b. _______________________________________ ________________________ _______________________c. _______________________________________ ________________________ _______________________
Even if parent/guardian cannot be reached, do not hesitate to medicate or call 911. 2. _________________________________________________________________________________________________
❑ The school may post this form in a visible location.
❑ If the patient presents to the emergency department, please monitor the patient for a biphasic reaction for at least ______ hours.
❑ Two doses of Epinephrine should be kept at school in case a repeat dose is needed.
❑ The student is capable and has been instructed in the proper method of self administering the medications named above and
may carry the medicines during school hours.
______________________________ ________________________________ ______________________________
Physician/Provider Signature Parent Signature Principal Signature
TRAINED STAFF MEMBERS 1. _______________________________________________________________________________ Room _______ 2. _______________________________________________________________________________ Room _______ 3. _______________________________________________________________________________ Room _______
Twinject® 0.3 mg and Twinject® 0.15 mg Directions
Hold black tip near outer thigh (always apply to thigh).
Remove caps labeled “1” and “2.”
Place rounded tip against outer thigh, press down hard until needle penetrates. Hold for 10 seconds, then remove.
to 10. Remove the EpiPen® unit and massage the injection area for 10
syringe from barrel by holding blue collar at needle base.
Put needle into thigh through skin, push plunger down all the way, and remove.
Once EpiPen® or Twinject® is used, call the Rescue Squad. Take the used unit with you to the Emergency Room. Plan to stay for observation at the Emergency Room for at least 4 hours.
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