Fillable NJ Allergy Health Care Plan (if Applicable)

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NJ Allergy Health Care Plan (if Applicable)

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  • 17 check-boxes
  • 39 other fields

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FORM
Allergy Health Care Plan: Operations Page 1 of 2
Effective Date: 03/2021
Allergy Health Care Plan
Child’s Name: _______________________________________ DOB: ___________________
Parent/Guardian Name: _______________________________ Phone: __________________
Physician’s Name: __________________________________ Phone:___________________
Allergen Treatment/Substitution
__________________________________ __________________________________
__________________________________ __________________________________
__________________________________ __________________________________
__________________________________ __________________________________
__________________________________ __________________________________
Type of allergy transmission/trigger: □ Ingestion □ Contact □ Inhalation
Note: Do Not Depend on Antihistamines or Inhalers to treat a SEVERE reaction. USE
EPINEPHRINE.
For the following signs of a mild allergic reaction, administer: _______________________
____________________________________________________________________________
□ Skin: Hives: Mild Itch □ Nose: Itchy, Runny, Sneezing
□ Stomach: Mild Nausea/Discomfort □ Mouth: Itchy
□ Other: ____________________________________________________________________
For any of the following signs of a SEVERE allergic reaction or a combination of
symptoms from different body areas, give EPINEPHRINE and CALL 911. If prescribed and
directed, give other medications (antihistamine/inhaler). Lay person flat. If breathing is
difficult or vomiting, place on side, or sit up.
□ Mouth: Significant Swelling of Tongue and/or Lips □ Heart: Pale, blue, faint, weak
pulse, dizzy
□ Throat: Tight, hoarse, trouble breathing/swallowing □ Lungs: Short of Breath
□ Skin: Many hives over body, widespread redness □ Stomach: Repetitive vomiting,
severe diarrhea
□ Other: Feeling something bad is about to happen; anxiety, confusion
Other Medication Instructions: _________________________________________________
____________________________________________________________________________
Extremely Reactive to the Following Foods____________________________________________;
therefore:
□ If checked, give epinephrine for ANY symptoms if the allergen was likely eaten.
□ If checked, give epinephrine immediately if the allergen was definitely eaten, even if no
symptoms are noted.
FORM
Allergy Health Care Plan: Operations Page 2 of 2
Effective Date: 03/2021
Prescribed Medications/Dosage
Epinephrine (brand and dose):__________________________________________________
Antihistamine (brand and dose):_________________________________________________
Other (e.g., inhaler-bronchodilator if asthmatic):______________________________________
____________________________________________________________________________
Potential Side Effects of Medication: ____________________________________________
____________________________________________________________________________
Potential Consequences to Child if Treatment is Not Administered: ___________________
____________________________________________________________________________
Staff Training:
Staff may be trained by:________________________________________________
_________________________________________________________
The following staff have been trained on the child’s medical condition:
_____________________________________ ____________________________________
_____________________________________ ___________________________________
This plan must be updated annually, or whenever there is any change in treatment, or the child’s
condition changes.
For complete medication administration information, it may be necessary for the medical provider
and parent/guardian to complete the Medication Authorization form.
Parent/Guardian Acknowledgement Statement
To ensure the safety of your child we cannot delete an allergy that has previously been
documented unless we have a signed note from the child’s physician stating that the child is no
longer allergic to that item(s) and may now have that specific food(s); or be exposed to the
item(s). Nor can we add an item(s) or change a medication without a signed note from the
child’s physician.
I understand that Bright Horizons requires the most up to date information regarding my child’s
allergy. I also understand that for the safety of my child, my child’s photograph and allergy
information will be posted in the classrooms and kitchen.
__________________________________________ _____________________________
Physician Signature Date
________________________________________ _____________________________
Parent/Guardian Signature Date
__________________________________________ _____________________________
Director/Principal Signature Date
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NJ Allergy Health Care Plan (if Applicable)

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Completed 8 September 2021

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