5141.25 Form

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!

Action:

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