Trinitypawling.org

Trinity-Pawling School
Health Center
700 Route 22
Phone 845 855-4848
Pawling, New York 12564
Fax 845 855-4851
Ema
[email protected]
Emergency Care Plan – Allergy
School Year 2011-2012

Student Name___________________________
Birthdate ___________________________ Grade ________

Identified Allergen(s) (drug/food/environmental) ___________________________________________________
History of Asthma
yes (w/ asthma, student has no
higher risk of severe reaction)

Contact Info:

Mother’s name _________________________ Phone (h) _______________ (w/c)________________

Father’s name _________________________ Phone (h)_______________ (w/c)_______________
Emergency contact ______________________ Phone (h)_______________ (w/c)________________

Parent signature _________________________
Date _______________
TREATMENT –
To be completed by a healthcare professional
If the student is e xperiencing the following symptoms, administer the indicated medication:
Symptoms
Give Checked Medication
General: Dizziness, loss of consciousness, feeling of panic or doom, chills ……………….( ) Epinephrine ( ) Benadryl
Mouth: Itching, tingling, swelling of lips, tongue, and/or mouth ………………………….( ) Epinephrine ( ) Benadryl
Breathing: Shortness of breath, wheezing, congestion, coughing, tightness in throat ….( ) Epinephrine ( ) Benadryl
: Nausea, vomiting, abdominal cramps, diarrhea…………………………….….( ) Epinephrine ( ) Benadryl
Hives, swelling on face or extremities, rash……………………….………….( ) Epinephrine ( ) Benadryl
Treatment sho uld be initiated IMMEDIATELY following exposure without waiting for symptoms to appear.
Treatment sh
ould be initiated only if symptoms (indicated above) appear.
Epinephrine: Inject intramuscularly - Epipen, 0.3 mg
Benadryl:
Give __________________________________________ (dosage/route)
Give __________________________________________ (medication/dosage/route)
Please check one of the following:
Student is capable of self-administration the following medication(s) ………………( ) Epinephrine ( ) Benadryl
Student is NOT capable of self-administration the following medication(s) .…….( ) Epinephrine ( ) Benadryl
Student c arries the following with him at all times………………………….…….( ) Epinephrine ( ) Benadryl
Physician’
s signature ___________________________
Date _______________________________
Physician’s name (print) ________________________
Phone number ______________________
If Epi-pen is administered, call 911 immediately!

Source: http://www.trinitypawling.org/uploaded/documents/medical_forms/Emergency_Care_Plan_-_Allergy_2.pdf