Allergy/Anaphylaxis 

Emergency Action Plan

PDF version: Anaphylaxis EAP

Student’s name:                                                                            Attach Student Photo Here

Date of birth:____/____/______

Age______Weight:_________kg

The student has allergy(ies) to ___________________________________________________________________________

Has the student had an anaphylactic reaction in the past? (Circle one) Yes No

Does the student have asthma? (Circle one) Yes No 

(If yes, the student is more likely to have a severe reaction)

May the student self-carry Epinephrine? (Circle one) Yes No 

IMPORTANT!

Anaphylaxis is a potentially life-threatening, severe allergic reaction. If in doubt, give epinephrine. 

For Severe Allergy and Anaphylaxis➠ If student has ANY of these severe symptoms after eating the food or having a sting, give epinephrine: Shortness of breath, wheezing, or coughing Skin color is pale or has a bluish color Weak pulse Fainting or dizziness Tight or hoarse throat Trouble breathing or swallowing Swelling of lips or tongue Vomiting or diarrhea (if severe or if combined with other symptoms) Many hives or redness over entire body Feeling of “doom,” confusion, altered consciousness, or agitation ▢ SPECIAL SITUATION: If this box is checked, then the student’s allergy is severe and must be given epinephrine even with mild symptoms.

➠GIVE EPINEPHRINE! Inject epinephrine right away. Note the time given. CALL 911.  Ask for ambulance with epinephrine Tell rescue squad when epinephrine was given Stay with student and: Call parents and student’s doctor Give second dose of epinephrine if symptoms get worse, continue, or do not get better within 5 minutes Give other medicine, if prescribed. Do not use other medicine in place of epinephrine. Antihistamine Inhaler/bronchodilator

For mild allergic reaction       ➠ If the student has had any mild symptoms, monitor the student. Symptoms may include: Itchy nose Sneezing Itchy mouth A few hives Mild stomach nausea or discomfort

➠ Monitor student Stay with the student, and:  Watch student closely Give antihistamine (if prescribed–see below) Call parents and child’s doctor If more than 1 symptom (to left) or symptoms of severe allergy and anaphylaxis develop (see above left box), give epinephrine.

Medications and Doses

Epinephrine, intramuscular (list type):_____________________________________

Dose (check one): ▢ 0.15 mg (less than 25 kg)

▢ 0.30mg (25 kg or more)

Antihistamine, by mouth (type and dose): __________________________________

Other (for example, inhaler/bronchodilator if child has asthma): ________________________________________________________________________________________________

Authorizations

 

________________________________ ____/____/________

Parent/Guardian Authorization Signature Date 

 

________________________________ ____/____/________

Parent/Guardian Authorization Signature Date 

 

________________________________ ____/____/________

Physician/HCP Authorization Signature Date

 

References

American Academy of Pediatrics. (2020). Allergy and anaphylaxis emergency form. Retrieved July 23, 

2020, from https://healthychildren.org/SiteCollectionDocuments/

AAP_Allergy_and_Anaphylaxis_Emergency_Plan.pdf

 

Food Allergy & Anaphylaxis Emergency Care Plan. (2020). Retrieved July 23, 2020, from 

https://www.foodallergy.org/living-food-allergies/food-allergy-essentials/

food-allergy-anaphylaxis-emergency-care-plan

 

Allergy and Anaphylaxis Emergency Plan

EMS Report Sheet

Student’s name:

Date of birth:____/____/______

Age______Weight:_________kg

The student has allergy(ies) to ___________________________________________________________________________

Other Medical History: 

 

Prescribed Medications:

 

Additional Instructions:

 

Contacts:

 

Primary Doctor: __________________________ Phone number: ______-______-__________

 

Parent/Guardian: _________________________ Phone number: ______-______-__________

 

Parent/Guardian: _________________________ Phone number: ______-______-__________

 

Other Emergency Contacts:

Name/Relationship: _______________________ Phone number: ______-______-__________

 

Name/Relationship: _______________________ Phone number: ______-______-__________

 

ACTIONS TAKEN:

 

Date: ____/____/________ Observed Reaction: ________________________

 

1st Dose Epinephrine Given: 

Time: _____:______AM/PM Site: _____________ Dose: ▢ 0.15 mg (less than 25 kg)

▢ 0.30mg (25 kg or more)

2nd Dose Epinephrine Given: 

Time: _____:______AM/PM Site: _____________ Dose: ▢ 0.15 mg (less than 25 kg)

▢ 0.30mg (25 kg or more)

 

***ANY USED EPINEPHRINE SYRINGES MUST BE GIVEN TO EMS***