Food Allergy Action Plan - University of Michigan

1 University OF Michigan HOSPITALS & HEALTH CENTERS DIVISION OF Allergy & CLINICAL IMMUNOLOGY BIRTHDATE: NAME: MRN: food Allergy Action plan Date: _____ Weight: _____ lbs Allergy to: _____ Asthma: Yes (high risk for severe reaction) No Action FOR MINOR REACTION 1. If only symptom(s) are: A few localized hives, give ANTIHISTAMINE. (see dose below) 2. Stay with student; call parents or emergency contacts. 3. Continue to observe child, if symptoms progress or fail to improve in 30 minutes, follow steps for MAJOR REACTION BELOW. SIGNS OF AN ALLERGIC REACTION Systems Symptoms MOUTH Itching or swelling of the lips, tongue or mouth THROAT Itchy throat, sensation of tightness, swelling, hoarseness, hacking cough SKIN Diffuse hives, itchy rash, redness swelling about the face or extremities STOMACH Nausea, abdominal cramps, vomiting, diarrhea LUNG Shortness of breath, repetitive coughing, wheezing HEART Weak pulse, passing out The severity of symptoms can quickly change.

2 * All above symptoms can potentially progress to a life-threatening situation. Action FOR MAJOR REACTION 1. Inject epinephrine IMMEDIATELY in thigh. 2. Call 911 and request an ambulance with epinephrine. Inform them that you have given epinephrine. 3. Give antihistamine (IF NOT VOMITING) and inhaler if history of asthma. 4. Stay with child at all times. 5. Lay child flat and raise legs. If vomiting, allow them to lay on their side or sit up. 6. If symptoms fail to improve or return, give another dose of epinephrine 5 minutes after the first dose. 7. Call parents or emergency contacts. MEDICATIONS/ DOSES Epinephrine Brand: _____ Epinephrine Dose: mg mg Antihistamine Brand or Generic: _____ Antihistamine Dose: _____ Other ( , inhaler-bronchodilator if asthmatic): _____ _____ _____ _____ _____ Parent/ guardian signature Date Physician/ Healthcare provider signature Date Place Child s Picture Here Form provided courtesy of the food Allergy Research & Education (FARE) ( ) 4/ 2013 EpiPen (epinephrine) Auto-Injector Directions First, remove the EpiPen (epinephrine) Auto-Injector from the plastic carrying case Pull off the blue safety release cap Hold orange tip near outer thigh (always apply to thigh) Swing and firmly push orange tip against outer thigh.

3 Hold on thigh for approximately 10 seconds. Remove EpiPen (epinephrine) Auto-Injector and massage the area for 10 more seconds. EpiPen , EpiPen 2-Pak , and EpiPen Jr 2-Pak are registered trademarks of Mylan Inc. licensed exclusively to its wholly-owned subsidiary, Mylan Specialty Auvi-QTM (epinephrine injection, USP) Directions Remove the outer case of Auvi-Q. This will automatically activate the voice instructions. Pull off RED safety guard. Place black end against outer thigh, then press firmly and hold for 5 seconds. 2002-2013 sanofi-aventis LLC. All rights reserved. Adrenaclick mg and Adrenaclick mg Directions Remove GREY caps labeled 1 and 2. Place RED rounded tip against outer thigh, press down hard until needle penetrates. Hold for 10 seconds, then remove. A food Allergy response kit should contain at least two doses of epinephrine, other medications as noted by the student s physician, and a copy of this food Allergy Action plan .

4 A kit must accompany the student if he/she is off school grounds ( , field trip). Contacts Call 911 (Rescue squad: (___) _____-_____) Doctor: _____ Phone: (___) _____-_____ Parent/Guardian: _____ Phone: (___) _____-_____ Other Emergency Contacts Name/Relationship: _____ Phone: (___) _____-_____ Name/Relationship: _____ Phone: (___) _____-_____