City of St. Charles R-6 School District
400 N. Sixth St., St. Charles, MO 63301
Contact: _________________________ Fax: __________________
Student Name: ___________________________ D.O.B.: _________ School Yr: _________
Allergy with possible anaphylaxis reaction:________________________________________
Other know food or medication allergies: _________________________________________
Medications currently taking: __________________________________________________
Emergency Contact Information: ___________________________ Phone: _____________
Secondary Contact Information: ___________________________ Phone: _____________
MILD REACTION: Symptoms:
Locate and follow student’s Individual Emergency Plan – Yes/No
Give medication as prescribed
Give Benadryl Standing Order
Benadryl (diphenhydramine hydrochloride liquid or tablets) Preschool – 5th Grade:
reaction without signs of anaphylaxis if
anaphylaxis if parents cannot be reached.
Call Parent Observe for additional symptoms Encourage student to be calm and relaxed
MODERATE REACTION: Symptoms:
Follow standing order for Epi-Pen®, Epi-
Inability to speak more than a few words
Provide support/comfort to student until
Directions for Administering Epi-Pen®
1. Pull off safety cap. (1) 2. Place tip on outer thigh at right angle to leg. (2) (For insect sting, inject leg opposite the sting.) 3. Press firmly into thigh. 4. Hold in place for 10 seconds. 5. Remove and massage area for 10 seconds.
Directions for Administering Twinject®
Remove caps labeled 1 and 2, or red cap, green cap.
Place rounded tip against outer thigh, press down hard until needle penetrates.
SECOND DOSE ADMINISTRATION
If symptoms don’t improve after 10 minutes, administer second dose:
Unscrew rounded tip, gray cap. Pull syringe from barrel by holding blue collar at
Slide yellow or orange collar off plunger.
Put needle into thigh through skin, push plunger down all the way, and remove.
Colorado Choice/SLVHMO Pharmacy Guide 700 Main Street, Suite 100 Alamosa, CO 81101 Phone: (719) 589-3696 Fax: (719) 589-4995 Communication of Information To ensure rapid patient care, effective communica- Telephone tion of information between prescribing physicians and Prescription Solutions Prior Authorization Team members is required. You need to provide
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