LA PORTE ISD ALLERGY EMERGENCY ACTION PLAN

Name: / Date:
Student Number: / School:
Birth Date: / Grade:
Severe Allergy to:

SIGNS OF AN ALLERGIC REACTION

Symptoms to look for:

• MOUTH / -itching & swelling of the lips, tongue or mouth, drooling
• THROAT* / - itching and/or a sense of tightness in the throat, hoarseness, and hacking cough, choking
• SKIN / - hives, itchy rash, and/or swelling about the face or extremities, flushed face
• STOMACH / - nausea, abdominal cramps, vomiting, and/or diarrhea
• LUNG* / - shortness of breath, repetitive coughing, and/or wheezing
• HEART* / - “thready” pulse, “passing-out”, rapid heart rate
• OTHER / - dizziness, unsteadiness, sudden fatigue, chills, loss of consciousness
The severity of symptoms can quickly change.
* Symptoms above can potentially progress to a LIFE-THREATENING situation.
*** Do not hesitate to call the nurse. If no nurse call 911 ***
Health Action Plan:
t Actions for Minor Reaction t
If only symptoms are ______,
give ______
Medication/ dose / route
t Actions for Major Reaction t
If symptoms include ______,
give ______immediately
Medication/dose/route
If Epipen is given call 911 afterwards.
Other health concerns:
Medications: / Dose/Time:
Dietary concerns/restrictions:
Parent Signature* / Date:
M.D. Signature * / Date:
* signature required
Contact Information:
Parent/Guardian:
1.______
2______ / Home phone:
Work: Cell:______

Work: Cell:______

Home Address: / Teacher: 4.
1. 5.
2. 6.
3. 7.
Emergency contact: / Phone:
Primary Care Physician: / Phone:
Specialty MD: / Phone:
School Nurse: / Phone:

IF EPIPEN IS RECOMMENDED, SEE DIRECTIONS BELOW:

Following resolution of an anaphylaxis emergency, nurse will complete the Anaphylaxis Incident Report form.

The La Porte Independent School District does not discriminate on the basis of race, religion, color, national origin, sex or disability in providing education services, activities, and programs, including vocational programs, in accordance with Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Educational Amendments of 1972; Section 504 of the Rehabilitation Act of 1973, as amended; and Title II of the Americans with Disabilities Act. The Title IX Coordinator is Isela Montes, Executive Director of Human Resources, 1002 San Jacinto, La Porte, Texas 77571, Telephone (281) 604-7110. The Section 504 Coordinator is Dr. April Fox, Executive Director of Special Programs, 1002 San Jacinto, La Porte, Texas 77571, Telephone (281) 604-7034.


El Distrito Independiente Escolar de La Porte no discrimina sobre la base de raza, religión, color, origen nacional, sexo u incapacidad para proveer servicios educacionales, actividades y programas, incluyendo programas vocacionales, de acuerdo con el Título VI del Acta de Derechos Civiles de 1964, como fue enmendada; Título IX de las Enmiendas Educacionales de 1972; Sección 504 del Acta de Rehabilitación de 1973, como fue enmendada; y el Título II del Acta de Americanos con Incapacidades. La Coordinadora del Título IX es Isela Montes, Directora Ejecutiva para Recursos Humanos, 1002 San Jacinto, La Porte, Texas 77571, Teléfono (281) 604-7110. La Coordinadora de la Sección 504 es la Dra. April Fox, Directora Ejecutiva de Programas Especiales, 1002 San Jacinto, La Porte, Texas 77571,

Teléfono (281) 604-7034.

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