Food Allergy Action Plan Form

• Name

• Date of Birth

  Date

• Allergy to

• Weight

• Asthma

  Yes

  No

• Conducted on

  Date

• Extremely reactive to the following foods:

• Therefore:

• If checked, give epinephrine immediately if the allergen was LIKELY eaten, for ANY symptoms.

• If checked, give epinephrine immediately if the allergen was DEFINITELY eaten, even if no symptoms are apparent.

• 

• 

Medications / Doses

• Epinephrine Brand or Generic:

• Epinephrine Dose:

  0.1 mg IM

  0.15 mg IM

  0.3 mg IM

• Antihistamine Brand or Generic:

• Antihistamine Dose:

• Other (e.g., inhaler-bronchodilator if wheezing):

Monitoring

• Stay with the student; alert healthcare professionals and parents. Tell rescue squad epinephrine was given; request an ambulance with epinephrine. Note time when epinephrine was administered. A second dose of epinephrine can be given 5 minutes or more after the first if symptoms persist or recur. For a severe reaction, consider keeping student lying on back with legs raised. Treat student even if parents cannot be reached. See back/attached for auto-injection technique.

Required Signatures

• Authorization Signature of Patient or Parent / Guardian

  Sign

• Authorization Signature of Physician / HCP

  Sign

Treatment Instructions

Emergency Contact - CALL 911

• Rescue Squad

• Phone #

• Doctor

• Phone #

• Parent / Guardian

• Phone #

Other Emergency Contacts

• Name

• Relationship

• Phone #