Food Allergy Action Plan Form PDF Details

Navigating daily life with food allergies requires vigilance, preparation, and clear communication. The Food Allergy Action Plan form serves as a critical tool in this endeavor, bridging gaps between individuals with allergies, their caregivers, educators, and healthcare providers. This comprehensive document outlines vital information such as the individual's name, date of birth, allergens, and specific instructions for managing an allergic reaction. It emphasizes the necessity of using epinephrine in the case of exposure to allergens and provides detailed steps for administering various brands of epinephrine auto-injectors. The plan also differentiates between severe and mild symptoms of an allergic reaction, instructing when to administer epinephrine or antihistamines, and when to call emergency services. Endorsed by the Food Allergy Research & Education (FARE) organization, this form aims to ensure that anyone responsible for a person with food allergies is fully informed on how to prevent and respond to an allergic emergency, underlining the importance of immediate action and the avoidance of reliance solely on antihistamines or inhalers for severe reactions.

QuestionAnswer
Form NameFood Allergy Action Plan Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfood allergy plan pdf, allergy action plan sample, allergy action pdf, allergy action plan printable

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Name:__________________________________________________________________________ D.O.B.:_____________________

 

PLACE

 

 

 

PICTURE

 

Allergic to:__________________________________________________________________________________________________

 

HERE

 

Weight:_________________ lbs. Asthma: Yes (higher risk for a severe reaction) No

 

 

 

 

 

 

 

NOTE: Do not depend on antihistamines or inhalers (bronchodilators) to treat a severe reaction. USE EPINEPHRINE.

 

 

Extremely reactive to the following allergens:_________________________________________________________

THEREFORE:

If checked, give epinephrine immediately if the allergen was LIKELY eaten, for ANY symptoms.

If checked, give epinephrine immediately if the allergen was DEFINITELY eaten, even if no symptoms are apparent.

FOR ANY OF THE FOLLOWING:

SEVERE SYMPTOMS

LUNG

HEART

THROAT

MOUTH

Shortness of

Pale or bluish

Tight or hoarse

Significant

breath, wheezing,

skin, faintness,

throat, trouble

swelling of the

repetitive cough

weak pulse,

breathing or

tongue or lips

 

dizziness

swallowing

 

 

 

 

OR A

SKIN

GUT

OTHER

COMBINATION

of symptoms

Many hives over

Repetitive

Feeling

from different

body, widespread

vomiting, severe

something bad is

body areas.

redness

diarrhea

about to happen,

 

 

 

anxiety, confusion

 

1.INJECT EPINEPHRINE IMMEDIATELY.

2.Call 911. Tell emergency dispatcher the person is having

anaphylaxis and may need epinephrine when emergency responders arrive.

Consider giving additional medications following epinephrine:

»Antihistamine

»Inhaler (bronchodilator) if wheezing

Lay the person flat, raise legs and keep warm. If breathing is difficult or they are vomiting, let them sit up or lie on their side.

If symptoms do not improve, or symptoms return, more doses of epinephrine can be given about 5 minutes or more after the last dose.

Alert emergency contacts.

Transport patient to ER, even if symptoms resolve. Patient should remain in ER for at least 4 hours because symptoms may return.

MILD SYMPTOMS

NOSE

MOUTH

SKIN

GUT

Itchy or

Itchy mouth

A few hives,

Mild

runny nose,

 

mild itch

nausea or

sneezing

 

 

discomfort

FOR MILD SYMPTOMS FROM MORE THAN ONE

SYSTEM AREA, GIVE EPINEPHRINE.

FOR MILD SYMPTOMS FROM A SINGLE SYSTEM

AREA, FOLLOW THE DIRECTIONS BELOW:

1.Antihistamines may be given, if ordered by a healthcare provider.

2.Stay with the person; alert emergency contacts.

3.Watch closely for changes. If symptoms worsen, give epinephrine.

MEDICATIONS/DOSES

Epinephrine Brand or Generic: _________________________________

Epinephrine Dose: 0.1 mg IM 0.15 mg IM 0.3 mg IM

Antihistamine Brand or Generic:_ _______________________________

Antihistamine Dose:___________________________________________

Other (e.g., inhaler-bronchodilator if wheezing): __________________

____________________________________________________________

PATIENT OR PARENT/GUARDIAN AUTHORIZATION SIGNATURE

DATE

PHYSICIAN/HCP AUTHORIZATION SIGNATURE

DATE

FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 5/2020

HOW TO USE AUVI-Q® (EPINEPHRINE INJECTION, USP), KALEO

3

1.

Remove Auvi-Q from the outer case. Pull off red safety guard.

 

2.

Place black end of Auvi-Q against the middle of the outer thigh.

 

3.

Press firmly until you hear a click and hiss sound, and hold in place for 2 seconds.

 

4.

Call 911 and get emergency medical help right away.

 

 

 

 

HOW TO USE EPIPEN®, EPIPEN JR® (EPINEPHRINE) AUTO-INJECTOR AND EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF EPIPEN®), USP AUTO-INJECTOR, MYLAN AUTO-INJECTOR, MYLAN

1.

Remove the EpiPen® or EpiPen Jr® Auto-Injector from the clear carrier tube.

 

2.

Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward. With your other hand,

 

 

remove the blue safety release by pulling straight up.

4

3.

Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’. Hold firmly in place for

 

 

3 seconds (count slowly 1, 2, 3).

 

4.

Remove and massage the injection area for 10 seconds. Call 911 and get emergency medical help right away.

 

 

 

 

 

 

HOW TO USE IMPAX EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF ADRENACLICK®),

 

USP AUTO-INJECTOR, AMNEAL PHARMACEUTICALS

5

1.Remove epinephrine auto-injector from its protective carrying case.

2.Pull off both blue end caps: you will now see a red tip. Grasp the auto-injector in your fist with the red tip pointing downward.

3.Put the red tip against the middle of the outer thigh at a 90-degree angle, perpendicular to the thigh. Press down hard and hold firmly against the thigh for approximately 10 seconds.

4.Remove and massage the area for 10 seconds. Call 911 and get emergency medical help right away.

HOW TO USE TEVA’S GENERIC EPIPEN® (EPINEPHRINE INJECTION, USP) AUTO-INJECTOR,

 

TEVA PHARMACEUTICAL INDUSTRIES

5

1. Quickly twist the yellow or green cap off of the auto-injector in the direction of the “twist arrow” to remove it.

2.Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward. With your other hand, pull off the blue safety release.

3.Place the orange tip against the middle of the outer thigh at a right angle to the thigh.

4.Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’. Hold firmly in place for 3 seconds (count slowly 1, 2, 3).

5.Remove and massage the injection area for 10 seconds. Call 911 and get emergency medical help right away.

HOW TO USE SYMJEPI™ (EPINEPHRINE INJECTION, USP)

1. When ready to inject, pull off cap to expose needle. Do not put finger on top of the device.

2

2.Hold SYMJEPI by finger grips only and slowly insert the needle into the thigh. SYMJEPI can be injected through clothing if necessary.

3.After needle is in thigh, push the plunger all the way down until it clicks and hold for 2 seconds.

4.Remove the syringe and massage the injection area for 10 seconds. Call 911 and get emergency medical help right away.

5.Once the injection has been administered, using one hand with fingers behind the needle slide safety guard over needle.

ADMINISTRATION AND SAFETY INFORMATION FOR ALL AUTO-INJECTORS:

1.Do not put your thumb, fingers or hand over the tip of the auto-injector or inject into any body part other than mid-outer thigh. In case of accidental injection, go immediately to the nearest emergency room.

2.If administering to a young child, hold their leg firmly in place before and during injection to prevent injuries.

3.Epinephrine can be injected through clothing if needed.

4.Call 911 immediately after injection.

OTHER DIRECTIONS/INFORMATION (may self-carry epinephrine, may self-administer epinephrine, etc.):

Treat the person before calling emergency contacts. The first signs of a reaction can be mild, but symptoms can worsen quickly.

EMERGENCY CONTACTS — CALL 911

OTHER EMERGENCY CONTACTS

RESCUE SQUAD: _______________________________________________________________________

NAME/RELATIONSHIP:_____________________________________ PHONE: ____________________

 

DOCTOR:__________________________________________________ PHONE: ____________________

NAME/RELATIONSHIP:_____________________________________ PHONE: ____________________

PARENT/GUARDIAN: _______________________________________ PHONE: ____________________

NAME/RELATIONSHIP:_____________________________________ PHONE: ____________________

 

FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 5/2020

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allergy action plan printable blanks to fill in

Type in the requested particulars in anaphylaxis and may need, Consider giving additional, Antihistamine Inhaler, MEDICATIONSDOSES, Epinephrine Brand or Generic, Epinephrine Dose mg IM mg IM, Lay the person flat raise legs, Antihistamine Brand or Generic, difficult or they are vomiting let, If symptoms do not improve or, Alert emergency contacts, Antihistamine Dose, Other eg inhalerbronchodilator if, Transport patient to ER even if, and remain in ER for at least hours part.

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In the OTHER DIRECTIONSINFORMATION may, Treat the person before calling, EMERGENCY CONTACTS CALL, OTHER EMERGENCY CONTACTS, RESCUE SQUAD, NAMERELATIONSHIP PHONE, DOCTOR PHONE, NAMERELATIONSHIP PHONE, PARENTGUARDIAN PHONE, NAMERELATIONSHIP PHONE, and FORM PROVIDED COURTESY OF FOOD part, point out the essential data.

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