20 ENDICOTT ROAD TOPSFIELD, MASSACHUSETTS 01983 (978) 887-2323
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Student__________________________________________________
D.O.B. __________________ Grade__________________________
Date of Diagnosis____________ Date of last reaction____________
Is your child asthmatic Yes No
Has your child ever had a serious reaction? Yes
No
Date:______________________
If so, please
describe what happened and treatment required:_____________________________
______________________________________________________________________________
______________________________________________________________________________
Check any life-threatening allergy your child has:
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Insect stings (list type) |
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Food (list type) Type of allergy: Ingestion Contact Inhalation |
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Animals (list type) |
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Other (list) |
The following are all signs of a serious allergic reaction. Please check the signs that are usually present for your child during an allergic reaction:
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Difficulty breathing, repetitive coughing, wheezing |
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Itchy rash, hives |
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Difficulty swallowing, sense of itching tightness or swelling in throat, hoarseness |
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Nausea, vomiting, diarrhea, abdominal cramps |
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Loss of consciousness, thready pulse |
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Flush/ unusually pale skin |
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Swelling: How much? Where? |
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Other |
Action for minor reaction:
If ingestion is suspected and the only symptom(s) are one or two hives and a small amount of itching, give__________________________________________________________________
(medication/dose/route)
The severity of symptoms can quickly change. All above symptoms can potentially progress to a life-threatening situation!
Action for systemic reaction:
If ingestion is suspected and/or any of the other symptoms above are present, IMMEDIATELY give the medication listed here and call 911________________________________________
_____________________________________________________________________________
(medication/dose route)
EMERGENCY CARE IN SCHOOL:
Stay with student, call or have someone call for nurse immediately.
Ask student if he/she uses an Epi-pen and if he/she has one with them.
Send another person to get the Epi-pen if available.
If nurse not present or available, someone trained in Epi-pen administration should give Epi-pen.
Never send a student to the nurse alone if symptoms noted above are present.
STUDENTS ARE EXPECTED TO CARRY THEIR OWN EPI-PEN AT ALL TIMES,
and it is recommended that a spare Epi-pen be kept in the nurse’s office.
Does your child require a peanut/tree nut free table? Yes No
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Epi-Pen Directions:
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EMERGENCY CONTACTS:
Name:__________________________Relation:_____________Cell Phone____________Work/home________
Name__________________________ Relation______________Cell Phone____________Work/home_______
I give my permission for the use of my child’s photograph for this purpose and to share medical information with appropriate school related personnel Yes______ No______
I give my permission for the school nurse to speak with my child's PCP regarding this diagnosis and to share with necessary school personnel information included in this document Yes_____ No______
I give permission for the school nurse or his/her delegated personnel to administer the medications at school or on school related events. Yes___________ No_____________
This student has permission to self-administer the
medications at school or on school related events, if the school nurse deems it
is appropriate. Yes________
No_____________
Parent’s Signature__________________________________________date_______________
Doctor’s Signature__________________________________________date________________
School Nurse Signature_____________________________________ date________________