Allergy and Anaphylaxis Emergency Plan Student Name* Grade* Date of Birth MM slash DD slash YYYY Teacher’s Name Child has allergy to*(Please indicate if reaction is also by contact or by inhaling the allergen)Child has asthma (if yes, higher chance of severe reaction)* Yes No Child has had anaphylaxis* Yes No Child may carry medicine* Yes No Child may give him/herself medicine (If the child refuses/is unable to self-treat, an adult must give medicine)* Yes No Does the child know what food/allergen to avoid?Will you be providing meals and snacks for your child at school?What age was your child when diagnosed?Reason for giving diagnosis.*In case of severe allergy and anaphylaxis, administer :*Additional Instructions:IMPORTANT REMINDER Anaphylaxis is a potentially life-threatening, severe allergic reaction. If in doubt, give epinephrine. For severe Allergy and Anaphylaxis What to look forIf the child has ANY of these severe symptoms after eating the food or having a sting, give epinephrine. Shortness of breath, wheezing, 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 that bother breathing Vomiting or diarrhea (If severe or combined with other symptoms) Many hives or redness over body Feeling of ‘doom’, confusion, altered consciousness of agitation Give Epinephrine!What to do Inject epinephrine right away!. Note the time when epinephrine was given. Call Ambulance Ask for the ambulance with epinephrine. Tell rescue squad when epinephrine was given. Stay with the child and; Call parents and child’s doctor. Give a second dose of epinephrine, if symptoms get worse, continue or do not get better in 5 minutes. Keep child lying on back. If the child vomits or has trouble breathing, keep the child lying on his or her side. Give other medicine, if prescribed. Do not use other medicine in place of epinephrine. Antihistamine Inhaler/Bronchodilator SPECIAL SITUATION SPECIAL SITUATION If this box is checked, the child has an extremely severe allergy to an insect sting or the following food(s):Food (s) Even if child has MILD symptoms after a sting or eating these foods, give epinephrine. For MIld Allergic Reaction What to look forIf child has had any mild symptoms, monitor child. Symptoms may include: Itchy nose, sneezing, itchy mouth A few hives Mild stomach nausea or discomfort Monitor ChildWhat to do Stay with child and : Watch child closely. Give antihistamine (If prescribed). Call parents and child’s doctor. If symptoms of severe allergy/anaphylaxis develop, use epinephrine. (See for severe allergy and anaphylaxis) Medicine DosesEpinephrine, intramuscular (list type): Dose* 0.15 mg 0.30 mg Expiration Date:* MM slash DD slash YYYY Comment Antihistamine, by mouth (type and dose): Expiration Date: MM slash DD slash YYYY Other (for example, inhaler/bronchodilator if child has asthma):Parent/ Guardian 1 Name:* Parent/ Guardian 1 Contact Number:* Parent/ Guardian 2 Name: Parent/ Guardian 2 Contact Number: Emergency Contact Name: Relationship Emergency Contact Number: Signature*Email:* Date* MM slash DD slash YYYY