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SNAP ALLERGY MEDICAL ACTION PLAN

Child’s Name

(to be completed by Health Care Provider) Date of Birth

Date

Sponsor Name

Health Care Provider

Health Care Provider Phone

Allergies (please list)

Symptoms MOUTH THROAT SKIN STOMACH LUNG HEART OTHER

Itching, tingling or swelling of lips, tongue and/or mouth Itching, tightness/closure, hoarseness, hacking cough Itching, hives, redness, swelling, rash Vomiting, diarrhea, cramps, nausea Shortness of breath, cough, wheeze Weak pulse, dizziness, passing out, blueness and pale

_______

_______________________________________

Oral

Injectable

Oral

Injectable

Oral

Injectable

Oral

Injectable

Oral

Injectable

Oral

Injectable

Oral

Injectable

Treatment Protocol (Indicate order medication is to be given)

Oral: (call parent)

  • Benadryl dosage: ______________

  • Inhaler, ______________________

  • Other ________________________

1st 2nd 3rd 1st 2nd 3rd 1st 2nd 3rd

Injectable: (call 911)

1st 2nd 3rd

  • EpiPen®

  • EpiPen® Jr.

  • Twinject 0.3 mg

  • Twinject 0.15 mg

Emergency Response

Administer rescue medication as prescribed above Stay with child Contact parents/guardian Seek emergency medical care if the child has _____

_______________________________________

IF THIS HAPPENS GET EMERGENCY HELP

NOW! CALL 911

  • Hard time breathing with:

    • o

      Chest and neck pulled in with breathing

      • o

        Child is hunched over

      • o

        Child is struggling to breathe

  • Trouble walking or talking

  • Stops playing and can’t start activity again

  • Lips and fingernails are gray or blue

Follow Up

This Allergy Medical Action Plan will be updated/revised whenever medications or child’s health status changes. If there are no changes, the Allergy Medical Action Plan will be updated at least every 12 months.

Child’s Name

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