Download/Print Copy of General Allergy Health Care Plan
Belgrade School District 44 Allergy Health Care Plan School Year:
Download/Print Copy of General Allergy Health Care Plan
- Name
- School
- Date
- Teacher
- Grade
- DOB
- Asthmatic?
- Yes*
- No
- *if yes, increased risk for severe reaction.
- Severe Allergy to:
Step 1: Signs and Symptoms of an Allergic Reaction
If Student has these Symptoms: | Give These Medications | ||
---|---|---|---|
Antihistamine | Epinephrine | ||
Mouth | Itching, tingling, or mild swelling of the lips | ||
Skin | Mild hives, itchy rash | ||
Skin | Mild hives, itchy rash unresponsive to antihistamine after 20 minutes | ||
Skin | Severe hives, swelling of face or extremities | ||
Gut | Nausea, abdominal cramps, vomiting, diarrhea | ||
Throat | Tightening of throat, hoarseness, hacking cough | ||
Lung | Shortness of breath, repetitive coughing, wheezing | ||
Heart | Thready pulse, low blood pressure, fainting, pale | ||
Other |
- Antihistamine to give
- Epinephrine to give
- Primary Care Provider, please check medication boxes above and sign here:
- Signature
- Date
Step 2: Emergency Calls
- Call 911
- State that an allergic reaction has occurred and additional epinephrine may be needed.
- Call Parent/Guardian
- Home Phone
- Work
- Cell
- Emergency Contact
- Phone
- Primary Care Physician
- Phone
- School Nurse
- Phone
- Other Health Concerns
- Other Medications
- Dose/Time
- Dietary Concerns/Restrictions
- Parent Signature
- Date
Individual Considerations:
Bus-Transportation should be alerted to student’s allergy
- This student carries Epipen on the bus YES NO
- Epipen can be found in: Backpack On person Other: (specify)
- Other:
Field Trip Procedures: Epipen should accompany student during any off campus activities
- Special instructions: