3300 - 1 1b STU 206 04 - 17R 3 years Campus _____________________ Attach Photo Here Northside Independent School District Health Services Department Anaphylaxis/Insect Aller g y Action Plan Physician Order Form Name:_______________ _______________ ___________ Student ID#: _________ D.O.B. __/__/__ Wt: ____ lbs Allergy:____________________________________________ Medication/Doses Epinephrine (brand/ dose): _____________ ______________ _______________________ _____ ___ _ _____ Antihistamine (brand/ dose): __________________________ _______________ ________ ___ ___ _____ __ Is the student Asthmatic? ____Yes ____No Bronchodilator (brand / dose): ____ ____ __ ________________ Treatment Plan: Physician to check appropriate medication(s) Allergen Exposure – no symptoms ___Epinephrine ___Antihistamine Respiratory – wheezing, shortness of breath, coughing ___Epinephrine ___Antihistamine Cardiovascular – low blood pressure, weak pulse, pallor/blue ___Epinephrine ___Antihistamine GI – nausea, vomiting, diarrhea, cramping ___Epinephrine ___Antihistamine Skin – hives, itching, rash, swelling of face/extremities ___Epinephrine ___Antihistamine Mouth – swelling lips/tongue, itching, tingling ___Epinephrine ___Antihistamine Throat – tightening, hoarseness, coughing ___Epinephrine ___Antihistamine Other - _________________________________ ___Epinephrine ___Antihistamine Symptom Worsening - _____________________ ___Epinephrine ___Antihistamine Parent consents for nurse follow up with physician ___Yes ___No _________ ____________________ _________ Parent Signature Date Physicia n re c ommendation s fo r medicat i o n se l f - admin i stration : (In i tia l one) T he s t uden t abov e ha s b ee n instruct e d b y m e i n th e prope r wa y t o us e h i s / h e r m e d i ca ti on( s ). It i s m y p r of e ss io nal opi n i on t hat he / s he be a llo wed t o c a rry a nd se l f – ad m i n i s te r t he a b o ve m e d i ca ti ons w h il e o n s c h ool p ro per t y o r at s c h o ol re late d e ven t s T he s t u d ent a bo ve i n m y p r of e ss io nal op i n io n s h ou l d N OT be a llowe d t o ca r ry a n d se l f - a d m i n i s t e r a ny o f t he a b o ve m e d icati o n(s ) w h il e on sch ool p ro p er t y or a t scho ol relate d e v e n ts. ________________________________________________ ___________________ Physician Signature / Phone # Date