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Food Allergy Action Plan Form – Fill Out and Use

The Food Allergy Action Plan Form is a food allergy management plan put together by the Food and Drug Administration with information about managing any of your dietary restrictions.

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Food Allergy Plan Printable Details

Do you or someone in your family suffer from food allergies? If so, you know how important it is to have an action plan in place. The Food Allergy Action Plan Form can help make sure you are prepared for any situation that may arise. This form includes a list of all common allergens, as well as instructions for what to do in case of an allergic reaction. It is important to always have this form with you, especially if you are traveling. With the Food Allergy Action Plan Form, you can rest assured that you will be able to handle any situation that comes up. You can download a copy of the form below.

Here is some specifics to help you find out how long it will require to finish the food allergy action plan form.

Question	Answer
Form Name	Food Allergy Action Plan Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	48
Avg. time to fill out	10 min 10 sec
Other names	food allergy management plan, allergy action form, allergy action printable, food allergy plan sample

Form Preview Example

Food Allergy Action Plan

Student’s

Name:__________________________________D.O.B:_____________Teacher:_____________________

ALLERGY TO:______________________________________________________________

Asthmatic Yes*

*Higher risk for severe reaction

Place

ChildÕs

Picture

Here

					 STEP 1: TREATMENT 
Symptoms:			!	!	!	!	!	!	!	Give Checked Medication**:
										(To be determined by physician authorizing treatment)
 If a food allergen has been ingested, but no symptoms:										 Epinephrine	 Antihistamine
	Mouth		Itching, tingling, or swelling of lips, tongue, mouth							 Epinephrine	 Antihistamine
	Skin		Hives, itchy rash, swelling of the face or extremities							 Epinephrine	 Antihistamine
	Gut		Nausea, abdominal cramps, vomiting, diarrhea							 Epinephrine	 Antihistamine
	Throat		Tightening of throat, hoarseness, hacking cough							 Epinephrine	 Antihistamine
	Lung		Shortness of breath, repetitive coughing, wheezing							 Epinephrine	 Antihistamine
	Heart	 	Thready pulse, low blood pressure, fainting, pale, blueness							 Epinephrine	 Antihistamine
	Other		_______________________________________							 Epinephrine	 Antihistamine
 If reaction is progressing (several of the above areas affected),									give	 Epinephrine	 Antihistamine

The severity of symptoms can quickly change. Potentially life-threatening.

DOSAGE

Epinephrine: inject intramuscularly (circle one) EpiPen¨ EpiPen¨ Jr. Twinjectª 0.3 mg Twinjectª 0.15 mg (see reverse side for instructions)

Antihistamine: give____________________________________________________________________________________

medication/dose/route

Other: give___________________________________________________________________________________________

medication/dose/route



 STEP 2: EMERGENCY CALLS 



1.Call 911 (or Rescue Squad: ________________________ ) . State that an allergic reaction has been treated, and additional epinephrine may be needed.

2.Dr. ____________________________________ at ____________________________________

3.Emergency contacts:

Name/Relationship	Phone Number(s)
a. ____________________________________________	1.)________________________	2.) ______________________
b. ____________________________________________	1.)________________________	2.) ______________________
c. ____________________________________________	1.)________________________	2.) ______________________

EVEN IF PARENT/GUARDIAN CANNOT BE REACHED, DO NOT HESITATE TO MEDICATE OR TAKE CHILD TO MEDICAL FACILITY!

Parent/Guardian Signature_________________________________________________	Date_______________
DoctorÕs Signature_______________________________________________________	Date_______________

(Required)

TRAINED STAFF MEMBERS
1. ____________________________________________________	Room ________
2. ____________________________________________________	Room ________
3. ____________________________________________________	Room ________

EpiPen¨ and EpiPen¨ Jr. Directions

Pull off gray activation cap.

Hold black tip near outer thigh (always apply to thigh).

Swing and jab firmly into outer thigh until Auto-Injector mechanism functions. Hold in place and count to 10. Remove the EpiPen¨ unit and massage the injection area for 10 seconds.

Twinjectª 0.3 mg and Twinjectª 0.15 mg Directions

Pull off green end cap, then red end cap.

Put gray cap against outer

thigh, press down firmly until needle penetrates. Hold for 10 seconds, then remove.

SECOND DOSE ADMINISTRATION: If symptoms donÕt improve after

10 minutes, administer second dose:

 Unscrew gray cap and pull syringe from barrel by holding blue collar at needle base.

 Slide yellow or orange collar off plunger.

Put needle into thigh through skin, push plunger down

all the way, and remove.

Once EpiPen¨ or Twinjectª is used, call the Rescue Squad. Take the used unit with you to the Emergency Room. Plan to stay for observation at the Emergency Room for at least 4 hours.

For children with multiple food allergies, consider providing separate Action

Plans for different foods.

**Medication checklist adapted from the Authorization of Emergency Treatment form	!

developed by the Mount Sinai School of Medicine. Used with permission.



How to Edit Food Allergy Action Plan Form

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portion of fields in allergy action printable

Indicate the data in  Mouth  Skin  Gut  Throat† ,  Epinephrine  Antihistamine,  Epinephrine  Antihistamine,  Epinephrine  Antihistamine, Thready pulse, If reaction is progressing, The severity of symptoms can, medication/dose/route, medication/dose/route,   STEP 2: EMERGENCY CALLS,     1, and may be needed.

Filling in allergy action printable stage 2

The software will request for more information to automatically fill out the box may be needed, Phone Number(s), EVEN IF PARENT/GUARDIAN CANNOT BE, and (Required).

allergy action printable may be needed, Phone Number(s), EVEN IF PARENT/GUARDIAN CANNOT BE, and (Required) blanks to insert

Indicate the rights and obligations of the parties inside the paragraph EpiPen® and EpiPen® Jr, Twinject™ 0,  Hold black tip near outer thigh, and  Pull off green end cap.

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Food Allergy Action Plan Form – Fill Out and Use

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