Emergency Healthcare Plan

ALLERGY TO:_________________________________________________________________

Student's Name:__________________________D.O.B.____________Teacher______________

Asthmatic? Yes*_____   No_____     *High risk for severe reaction

SIGNS OF AN ALLERGIC REACTION INCLUDE:
Systems Symptoms
MOUTH Itching and swelling of the lips, tongue, or mouth
THROAT Itching and/or a sense of tightness in the throat, hoarseness, and hacking cough
SKIN Hives, itchy rash, and/or swelling about the face or extremities
GUT Nausea, abdominal cramps, vomiting, and/or diarrhea
LUNG Shortness of breath, repetitive coughing, and/or wheezing
HEART "Thready" pulse, passing out
The severity of symptoms can quickly change. *All above symptoms can potentially progress to a life-threatening situation!

ACTION:

  1. If Contact is suspected, give ______________________________________________________
                                                                                Medication/dose/route
    and __________________________________________________immediately!
  2. CALL RESCUE SQUAD (Request Epinephrine):_______________________________________
  3. CALL: Mother______________________Father__________________________or emergency contacts
  4. CALL: Dr. ____________________________________________at ______________________
  5. Will student carry emergency medication on his/her person? yes_____ no _____
  6. Instructions for bus driver if applicable_______________________________________________

          ____________________________________________________________________________

         ____________________________________________________________________________

DO NOT HESITATE TO ADMINISTER MEDICATION OR CALL RESCUE SQUAD EVEN IF PARENTS OR DOCTOR CANNOT BE REACHED!

___________________________   __________   ________________________M.D. _____________
         Parent Signature                                Date                Doctor's Signature                            Date   

EMERGENCY CONTACTS TRAINED STAFF MEMBERS
1. _____________________________________

    Relation:______________Phone:___________

2. _____________________________________

    Relation:______________Phone:___________

3. _____________________________________

    Relation:______________Phone:___________

 1. ________________________Room________

2. ________________________Room________

3. ________________________Room________