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1.7: Food Allergy Action Plan

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    40931
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    Food Allergy Action Plan

    Consent for Emergency Medical Treatment

    I, the undersigned parent/guardian of the child listed below, authorize the staff of [Program/School Name] to administer necessary medication and treatment in the event of an allergic reaction. I understand that every effort will be made to contact me immediately during an emergency. If I cannot be reached, I consent to the administration of emergency medical care as recommended by a licensed healthcare professional. I also release and hold harmless the program, its staff, and medical personnel from any liability resulting from the emergency treatment administered in good faith for my child.

     

    Child Information

    Home:            

    Work: 

    Mobile: 

     

    Allergy Details

    Known Allergies

    • Symptoms to Watch for:
      • Hives or red, itchy skin
      • Swelling of face, lips, tongue, or throat
      • Difficulty breathing or wheezing
      • Stomach pain, vomiting, or diarrhea
      • Pale or blue skin color
      • Loss of consciousness

     

    Medication and Dosage

    Medication Name:

    Dosage: 

    Time of Administration: 

    Storage Location of Medication: 

    Special Instructions   

    Emergency Action Plan

    Emergency action plan
    Emergency Treatment Question Action
    Is the child having mild symptoms (e.g., itching, hives)? Administer antihistamine as prescribed. Monitor for changes.
    Is the child showing severe symptoms (e.g., difficulty breathing)? Administer epinephrine (if prescribed) immediately and call 911.
    Has emergency medication been administered? Stay with the child, monitor breathing, and alert emergency contacts.

     

    Emergency Contacts

    1. Contact Name: 

    Relationship to Child: 

    Phone Number(s)

     

    2. Contact Name: 

    Relationship to child: 

    Phone Number(s)

     

    Signature Section

    Parent/Guardian Signature:

    Date:

     

    Physician's Signature (If required):

    Date:


    1.7: Food Allergy Action Plan is shared under a CC BY-NC 4.0 license and was authored, remixed, and/or curated by LibreTexts.

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