SCHOOL STING ALLERGY RECORD

And

Emergency Action Plan

Please Complete both sides of the emergency medical plan for Sting Allergy and add any further instructions you wish for your child.

Return to School Nurse as soon as possible.

NAME OF STUDENT ______

1. List sting allergies (which insects cause reaction):______

2. Briefly describe what happens during an allergic reaction______

3. Does your child require medication during an allergic reaction? ______If so, please list: ______

4. Has your child been to the doctor or to an emergency room due to an allergic reaction? ______

5. Does your child require medical care after an allergic reaction? ______

6. What steps do you want school personnel to take if your child develops an allergic reaction? ______

______

7. Does your child use an Epi-Pen or ANA kit? ______

8. In the event that you cannot be contacted, please list names and emergency phone numbers of persons

familiar with your child’s allergy______

______

PLEASE NOTE: If medication (Benadryl/Epi-Pen) is to be kept or taken at school, a medication authorization form must be completed by parent and physician and kept at the school. These are obtained from your school nurse. This form is completed each year.

PLEASE READ THE EMERGENCY MEDICAL PLAN FOR ALLERGIES ON THE REVERSE SIDE AND ADD ANY FURTHER INSTRUCTIONS THAT YOU WISH FOR YOUR CHILD.

STUDENT NAME______TEACHER______GRADE______

BUS#______PRIMETIME ____am ____pm CAR RIDER ____ am _____ pm

PARENT/GUARDIAN______HOME PHONE ______WORK PHONE______

CELL PHONE ______

PRIMARY PHYSICIAN______PHONE ______

ALLERGY SPECIALIST ______PHONE ______

HOSPITAL______

______

ALLERGIC REACTION SYMPTOMS

Redness/Itching around mouthHivesShortness of BreathWheezing

Swelling of lips, tongue, faceRed itchy blotches over skinsSwelling of the ThroatFear

Hoarseness/coughFlushed SkinPainful constriction of the chestRapid Pulse

Diarrhea/Nausea/VomitingFeeling of itching insideRestlessnessUnconciousness

______

Please circle or add symptoms pertinent to your child

Intervention:

  1. SEND CHILD TO SCHOOL NURSE (IF IN BUILDING) OR MAIN OFFICE IMMEDIATELY,

ACCOMPANIED BY ANOTHER PERSON

  1. Administer any ordered medication.

List emergency medication your child uses for reaction:______

______

  1. Contact parents immediately for pick-up or further instructions.
  1. Remove stinger, apply cool compress and elevate
  1. Keep child sitting up.
  1. STAY WITH CHILD CONTINUOUSLY!
  1. If no symptoms after 20 minutes, child may return to class with parent permission.
  1. Observe for signs of anaphylactic shock:

-increased swelling, hives-loss of color around lips

-vomiting-weak pulse

-respiratory distress

  1. Monitor breathing and begin rescue breathing as necessary
  1. CALL 911 AND TRANSPORT TO HOSPITAL
  1. Additional instructions______

______

I authorize the release and exchange of medical and educational information between my child’s physician and school staff necessary in carrying out this service to my child.

PARENT/GUARDIAN SIGNATURE______DATE______

SCHOOL NURSE SIGNATURE______DATE______