EMERGENCY HEALTH CARE PLAN
For students at high risk for severe allergic reaction to
food or bee sting
(Fill out a separate form for each allergy if the medical
response varies)
Student’s Name:_______________________________________ YOG________________
Allergy to:_________________________________________________________________
Special Considerations: ______________________________________________________
Signs of an allergic reaction include:
Symptoms
Mouth itching and swelling of the lips, tongue or mouth
Throat* itching and/or a sense of tightness in the throat,
hoarseness, and hacking couch
Skin hives, itchy rash and/or swelling about the
face or extremities
GI Tract nausea, abdominal cramps, vomiting and/or diarrhea
Lungs* shortness of breath, repetitive coughing and/or
wheezing
Heart* ‘thready”
pulse, “passing out”
The
severity of the above symptoms can quickly change.
*These
symptoms can potentially progress to a life-threatening situation!
Action:
1.
For signs of a severe allergic reaction, GIVE_____________________________________________________
(medication/dose/route)
immediately, followed
by____________________________________________ if needed.
******Ordering physician signature
__________________________________ Date ____________
2. CALL
Rescue Squad 911 if Epi-pen given.
3, CALL
parent/Guardian _____________________________________________ Phone ____________________
I
consent to have the school nurse or school personnel designated by the School
Nurse administer the medication prescribed by:
__________________________________________ to
____________________________________________
Licensed Prescriber Student’s Name
I
plan to keep an updated epi-pen in my child’s backpack at all times: _____ yes _____ no
I
give permission to the School Nurse to share information relevant to the
prescribed medication administration as he/she determines appropriate for my
son’s/daughter’s health and safety.
I
understand I may retrieve the medication from the school at any time: however,
the medication will be destroyed if it is not picked up within one week
following termination of the order or one week beyond the close of school.
Parent/Guardian
Signature:________________________________________ Date:______________________
Relationship to
student;___________________________________________
Emergency telephone numbers:
_____________________________ ____________________________