ALLERGIC REACTION HEALTH HISTORY
Student_____________________________________ School_______________
Grade/Teacher_______________________________ School Year___________
Check allergy(s) requiring treatment with medication:
Insect stings (list) ________________________________________________________
Food(s) (list) ____________________________________________________________
Animals (list) ____________________________________________________________
Other (list) ______________________________________________________________
Indicate the signs that are usually present during your child’s allergy attack:
□ Difficulty breathing □ Loss of consciousness □ Flushed or pale skin
□ Difficulty swallowing □ Nausea □ Hives/rash
□ Swelling of face, tongue, lips
□ Other _________________
Date of last reaction _____________Symptoms ________________________________________
Has emergency medical treatment been needed in the past for an allergic reaction?
□ Yes □ No If yes, when? Date________ Where? □ 911 □ Emergency Room
Physician treating child’s allergy_____________________ Phone______________________
Emergency medications used to treat allergic reaction Daily medications to control allergy
1. ___________________________________ 1. __________________________
2. ___________________________________ 2. __________________________
Is medication required for school in case of an allergic reaction? □ YES □ NO
___________________________________________ _____________________
Parent Signature Date
___________________________________ ___________________
School Nurse Signature Date Reviewed
Rev. 05/13/2011
In compliance with federal law, the Rowan-Salisbury School System administers all education programs, employment activities, and admissions without
discrimination because of race, religion, national or ethnic origin, color, age, military service, disability, or gender, except where exemption is appropriate
and allowed by law.
Allergic Reaction Emergency Treatment Plan
Student’s Name_______________________________________ D.O.B.__________________
ALLERGY TO ________________________________________________________________
Signs of an Allergic Reaction
Any SEVERE SYMPTOMS after suspected or known
Ingestion or exposure to allergen.
One or more of the following:
LUNG: Short o f breath, wheeze, repetitive cough
HEART: Pale, blue, faint, weak pulse, dizzy, confused
THROAT: Tight, hoarse, trouble breathing/swallowing
MOUTH: swelling of tongue and/or lips
SKIN: Many hives over body, swelling o f face or
extremities
Or combination o f s ymptoms from di f ferent body areas:
SKIN: Hi ves, itchy rashes, swelling (e.g., e yes, lips)
GUT: Vomiting, crampy pain, diarrhea, nausea
OTHER: __________________________________
MILD SYMPTOMS:
MOUTH: Itch y mouth
SKIN: A few hives around mouth/face, mild itch
GUT: Mild nausea
OTHER: _________________________________
If epinephrine injection is administered:
Stay with student; alert office staff. Tell EMS epinephrine was given; Note time when
epinephrine was administered. For a severe reaction keep student lying on his/her back with legs
raised. Treat student even if parent/guardian cannot be reached.
Trained Staff
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Rev. 05/13/2011