To be completed by healthcare provider
Colorado Allergy and Anaphylaxis Emergency Care Plan and Medication Orders
Student’s Name: _____________________________________D.O.B. __________ Grade: ____________
School: ____________________________________________ Teacher: ___________________________
ALLERGY TO: ____________
HISTORY: _______________________________________________________________________
______________________________________________________________________________________
Asthma: YES (higher risk for severe reaction) NO
STEP 1: TREATMENT
DOSAGE: Epinephrine: inject intramuscularly using auto injector (check one): 0.3 mg 0.15 mg
If symptoms do not improve ____minutes or more, or symptoms return, 2
nd
dose of epinephrine should be given
Antihistamine: (brand and dose)_______________________________________________________________
Asthma Rescue Inhaler: (brand and dose)________________________________________________________
Student has been instructed and is capable of carrying and self-administering own medication. Yes No
Provider (print) __________________________________________________Phone Number: ______________
Provider’s Signature: _____________________________________________ Date: _______________________
If this condition warrants meal accommodations from food service, please complete the medical statement for dietary disability
◊ STEP 2: EMERGENCY CALLS ◊
1. If epinephrine given, call 911. State that an allergic reaction has been treated and additional
epinephrine, oxygen, or other medications may be needed.
2. Parent: ________________________________ Phone Number: ____________________________
3. Emergency contacts: Name/Relationship Phone Number(s)
a. _______________________________________1) _______________ 2) ________________
b. _______________________________________ 1) ______________ 2) ________________
EVEN IF PARENT/GUARDIAN CANNOT BE REACHED; DO NOT HESITATE TO ADMINISTER EMERGENCY MEDICATIONS
I give permission for school personnel to share this information, follow this plan, administer medication and care for my child and, if necessary,
contact our health care provider. I assume full responsibility for providing the school with prescribed medication and delivery/monitoring devices.
I approve this Severe Allergy Care Plan for my child.
Parent/Guardian’s Signature: ______________________________________________ Date: _______________________
School Nurse: ___________________________________________________________ Date:
________________________
Place child’s
photo here
SEVERE SYMPTOMS: Any of the following:
LUNG: Short of breath, wheeze, repetitive cough
HEART: Pale, blue, faint, weak pulse, dizzy,
THROAT: Tight, hoarse, trouble breathing/swallowing
MOUTH: Significant swelling of the tongue and/or lips
SKIN: Many hives over body, widespread redness
GUT: Repetitive vomiting, severe diarrhea
OTHER: Feeling something bad is about to happen,
confusion
1. Alert parent and school nurse
2. Antihistamines may be given if ordered by
a healthcare provider,
3. Continue to observe student
4. If symptoms progress USE EPINEPHRINE
5. Follow directions in above box
1. INJECT EPINEPHRINE IMMEDIATELY
2. Call 911 and activate school emergency
response team
3. Call parent/guardian and school nurse
4. Monitor student; keep them lying down
5. Administer Inhaler (quick relief) if ordered
6. Be prepared to administer 2
nd
dose of
epinephrine if needed
*Antihistamine & quick relief inhalers are not to
be depended upon to treat a severe food
related reaction . USE EPINEPHRINE
MILD SYMPTOMS ONLY:
NOSE: Itchy, runny nose, sneezing
SKIN: A few hives, mild itch
GUT: Mild nausea/discomfort
Elizabeth Wilson
5/20/14
Wee Ones Child Care
Pamela Gordon
Diphenhydramine (Benadryl) 3.75 ml (3/4 tsp) by mouth
N/A
Sam Mackey
303-555-4141
6/9/17
Grace Wilson
303-555-2051
Katrina Wilson/Grandmother
303-555-4203
6/9/17
6/12/17
Severely allergic to peanuts; allergic to dust mites
Had allergic reaction to peanut product when she was two - swelling of the lips and tongue
Nora Hall, RN Consultant
Sam Mackey
Grace Wilson
Student Name: ___________________________________________________ DOB: ___________________________________
1.___________________________________________
Room _____________________________
2.___________________________________________
Room _____________________________
3.___________________________________________
Room _____________________________
Self-carry contract on file: Yes No
Expiration date of epinephrine auto injector: ____________________________________
NOTE: Consider lying on the back with legs elevated. Alternative positioning may be needed for vomiting (side lying,
head to side) or difficulty breathing (sitting)
Additional Information
C.R.S. 22-2-135(3)(b) 1/2017
Your Name
2c
Pamela Gordon
2a
8/30/18
Elizabeth Wilson
5/20/14
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