EMERGENCY HEALTH CARE PLAN
Place
Child’s
Picture
Here
ALLERGY TO: | |
Student’s Name | |
DOB: | |
Teacher: |
Asthmatic | YES * | No |
*Denotes HIGH RISK for severe reaction |
SIGNS OF AN ALLERGIC REACTION INCLUDE |
Systems: | Symptoms: |
MOUTH | itching and swelling of the lips, tongue, or mouth |
THROAT | itching and/or a sense of tightness in the throat, hoarseness, and hacking cough |
SKIN | hives, itchy rash, and/or swelling about the face or extremities |
GUT | nausea, abdominal cramps, vomiting and/or diarrhea |
LUNG | shortness of breath, repetitive coughing, and/or wheezing |
HEART | “thready” pulse, “passing out” |
The severity of symptoms can quickly change. *All above symptoms can potentially progress to a life-threatening situation! |
1. If ingestion is suspected, give (medication/dose/route)
immediately!
2. CALL RESCUE SQUAD:
3. CALL: Mother Father
or emergency contacts.
4. CALL: Dr. at
DO NOT HESITATE TO ADMINISTER MEDICATION OR CALL RESCUE SQUAD EVEN IF PARENTS OR DOCTOR CANNOT BE REACHED!
r Parent Signature Date Doctor’s Signature Date
Emergency Contacts | Trained Staff Members |
1. | 1. |
Name/Relation Phone | Name/Relation Phone |
2. | 2. |
Name/Relation Phone | Name/Relation Phone |
3. | 3. |
Name/Relation Phone | Name/Relation Phone |