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General Allergy Health Care Plan

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

  1. Call 911
    • State that an allergic reaction has occurred and additional epinephrine may be needed.
  2. Call Parent/Guardian
    • Home Phone
    • Work
    • Cell
  3. Emergency Contact
    • Phone
  4. Primary Care Physician
    • Phone
  5. School Nurse
    • Phone
  6. Other Health Concerns
  7. Other Medications
    • Dose/Time
  8. Dietary Concerns/Restrictions
  9. 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: