Food Allergy Action Plan Form – Fill Out and Use This PDF

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 Action Plan Form PDF 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?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	allergy action plan, allergy action plan sample, allergy action printable, food allergy plan pdf

12

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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
SKIN	GUT	OTHER	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.	3
	1.
	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	4
	3.
		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.	5

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 pdf blanks to fill in

Type in the requested particulars in MEDICATIONS, DOSES Epinephrine, Brand, or, Generic Epinephrine, Do, sem, gIM, mg, I, Mm, gIM Antihistamine, Brand, or, Generic Antihistamine, Dose PHYSICIAN, H, CP, AUTHORIZATION, SIGNATURE and DATE part.

step 2 to completing allergy action pdf

In the EMERGENCY, CONTACTS, CALL OTHER, EMERGENCY, CONTACTS RESCUE, SQUAD NAME, RELATIONSHIP, PHONE DOCTOR, PHONE NAME, RELATIONSHIP, PHONE PARENT, GUARDIAN, PHONE and NAME, RELATIONSHIP, PHONE part, point out the essential data.

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