Student Name:______________________________School:____________Grade/Section_____________

___________________________is allergic to the following insect sting, foods or

substances: ______________________________________________________________.

Accidental ingestion or sting could lead to a severe anaphylactic reaction:

A. Local Reaction to be expected in this child._______________________________ _______________________________________________________________________

(Common signs & symptoms include: redness, rash, itching, at the site. Course: May have slow progression of above symptoms but does not become an anaphylactic reaction.)

Treatment: Give diphenhydramine liquid (Benedryl) _____________tsp. ..........................................................................................(12.5mg/tsp)

B. Systemic reaction to be expected in this child___________________________

_____________________________________________________________________

(Common Signs & Symptoms include: Flushing, itching of scalp, hands. or skin of feet;hives, swelling of lips, tongue, face or throat; difficulty breathing, wheezing,shortness of breath, nausea, vomiting, fainting or actual collapse. Course: May lead to profound shock and cardiopulmonary arrest.)

Treatment: If signs and symptoms of a systemic reaction develop, administer: EpiPen___________mg. (Jr. epiPen=0.15mg; Regular EpiPen=0.3mg)

Immediately call 911 and transport to the nearest medical facility by ambulance.

Hospital and Phone Number:_______________________________________________ _______________________________________________________________________

Notify__________________________ at__________________________of the reaction. . . . . . . (parent/guardian) . . . . . . . . . . . . . . .(phone #)

Dr.______________________should be called at _____________________ regarding the reaction and or any questions.

Do not hesitate to administer medication or take the child to a medical facility even if the parents cannot be reached!

Physician's signature____________________________M.D./D.O. Date_____________

Parent's signature____________________________. . . . . . . . . . .Date_____________

Approved by Dr. J. Schrock, MD 9/96