Epi-pen individualized care plan.pub

Thompson Recreation
Epi-Pen Individualized Emergency Treatment Plan
Child’s Name_________________________________________________ Date of Birth ________________ Child’s Address ___________________________________________________________________________ Physician’s Name _____________________________________________ Phone ______________________ Physician’s Address ________________________________________________________________________ NO Food Allergy: __________________________________________________
IF PATIENT INGESTS OR THINKS HE/SHE HAS INGESTED THE ABOVE NAMED FOOD:
Anaphylaxis can occur up to 2 hours following ingestion of a food allergen

A. PROCEDURES FOR EMERGENCY TREATMENT: (check one)
_____ Administer medication before symptoms occur if patient ingests or thinks he/she has ingested the above
named food (if bee sting allergy - if stung)
_____ Observe patient for symptoms and administer medication if symptoms occur (circle symptoms below)
B. MEDICATION TO BE ADMINISTERED (please number in the order to be followed and circle appropriate medicine)
_____Administer adrenaline: Epi-Pen Jr. Epi-pen Sr.
_____Administer Benadryl ____ tsp or Atarax ___ tsp swish and swallow
_____Other:________________________________________________________________________________________________
_____Transport to ER (Call 911)
_____Contact parents
C. If FOOD ALLERGY, PLEASE INDICATE LEVEL OF CONTACT WHICH MAY CAUSE A REACTION::
_____Ingestion

E. SYMPTOMS OF ANAPHYLAXIS (circle all those that apply to this child)
Chest tightness, cough, shortness of breath, wheezing
Hives or swelling Itchy mouth, itchy skin Tightness in throat, difficulty swallowing, hoarseness Physician’s Signature ______________________________________________________________ Date____________________ ************************************************************************************************* FOR EPI PENS SELF ADMINISTRATION ONLY (Grade 5 and up): I have instructed this student in the proper use of an Epi-pen. It is my opinion that this child be allowed to carry and self-administer the epi-pen in the event of a sever reaction I give permission for Thompson Recreation/Purely Recreation/Adventure Camp personnel to administer the above medication, as indicated, to my child. Parent/Guardian Signature ______________________________________________________________ Date ___________________ FOR GRADE 5 AND UP ONLY - AUTHORIZATION FOR SELF-ADMINISTRATION OF THE ABOVE MEDICATION I request that my child, named above, be allowed to self administer the above ordered medication. I understand that my child will be responsible for transporting the pharmacy labeled medication to Thompson Recreation events and maintaining it in his/her control. Parent/Guardian Signature _____________________________________________________________ Date ___________________ Parent/Guardian Name (Please Print) ___ _________________________________________________________________________

Source: https://www.thompsonrec.org/documents/epipen_individualized_care_plan.pdf