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Emergency Health Care Plan                                                
ANAPHYLAXIS

STUDENT:  ________________________________    Teacher:  _________________________

ALLERGY TO:  _______________________________________________________________ Asthmatic  ______  Yes (High risk for severe reaction)  ______  No
Description of Reaction:  _________________________________________________________

Symptoms of an allergic reaction include:
**  Throat:   itching and/or a sense of tightness in the throat, hoarseness, and hacking
	         cough
       	**   Lung:    shortness of breath, repetitive coughing, and/or wheezing
	**   Heart:    “thready” pulse, “passing out”
	       Mouth:   itching and swelling of the lips, tongue, or mouth
	       Skin:      hives, itchy rash, and/or swelling about the face and extremities
	       Gut:       nausea, abdominal cramps, vomiting, and/or diarrhea
The severity of the symptoms can quickly change.
**  All above symptoms can potentially progress to a life-threatening situation!

ACTION:
1.	If ingestion or contact is suspected,
a.  For rash or no symptoms, give antihistamine _______________________;
     or ____________________________ and observe closely for worsening  
     symptoms

b.	For severe symptoms **, use EpiPen/EpiPen JR immediately and above 
medication(s),  then CALL 911, parent, and page school nurse at: ___________

Have someone stay with the child at all times until the paramedics arrive!

__________________________    __________    __________________________    __________
                   Parent                                 Date                             Doctor                                  Date

__________________________    __________    __________________________    __________
              School Nurse                          Date                         Administrator                            Date

Emergency Contacts
Mother: ______________________________      Father:  ___________________________
Home Phone:  __________________________      Home Phone: _______________________
Work Phone:  __________________________      Work Phone:   _______________________
Cell Phone:     __________________________      Cell Phone:      _______________________
Physician:  ____________________________     Physician’s Phone:  ___________________