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PACKER severe allergy
treatment Plan
nursing Office: tel. 718 250-0259 Fax: 718 250-0292 [email protected]
_______________________________________________________________________________ student’s last name, First name, middle name ________________________________________________________________________________________
complete Physician’s instructions. sign and date all areas.
________________________________________________________________________________________
________________________________________________________________________________________
if you suspect severe food, insect sting, or other severe allergic reaction:
medication doses
_____________________________
SYMPTOMS
GIVE MEDICATION CHECKED “X”
BENADRYL™
EPIPEN™
itching, tingling, or swelling oF lips, tongue, mouth ™ (liquid diphenhydramine, benadryl™):give ______________ teaspoon(s), hives, swelling on Face or extremities, itchy rash nausea, abdominal cramps, vomiting, diarrhea™ tightening oF throat, hoarseness, hacking cough™ shortness oF breath, repetitive coughing, wheezing thready pulse, passing out, Fainting, pale, blueness panic, sudden Fatigue, chills, Fear oF impending doom iF a Food allergen has been ingested, but no symptoms call 911 when symptoms occur. state
that the child has had a severe allergic
iF a reaction is progressing (several of the above areas affected): reaction, and additional epinephrine
iF a Food allergen may have been ingested, but no symptoms doses may be needed.
Physician information (please print)
Parent information (please print)
____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ _________________________________________________________ ____________________________________________________ ____________________________________________________ Physician’s stamP
____________________________________________________ Parent Permission for treatment
____________________________________________________ i permit the packer nursing staff to inform and update packer staff members of my child’s allergies and possible allergic reactions. i understand that either the nurse or my child's teach- ____________________________________________________ ers may advise other staff persons of my child's allergies, to ensure that all staff persons work-ing with my child understand her/his allergies and possible allergic reactions. i understand that in pre and lower school classes, teachers may discreetly post my child's picture, as part of ____________________________________________________ the procedure to ensure that other staff persons may identify my child as a student. i under- Please sign!
stand nursing or other packer staff members will contact my child’s physicians or contact PARENT’S SIGNATURE
emergency personnel to assist my child if a severe allergic reaction is suspected. i understand ____________________________________________________ nursing or other packer staff members will contact the parent or guardian as soon as possible.

Source: http://www.packer.edu/uploaded/downloads/Medical_Forms/SevereAllergyTreatmentPlan.pdf