Name of Individual: Location of Incident (School): Age: DOB: M 5 F 5 Spanish/Hispanic/Latino
Total Page：16
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Report of Epinephrine Administration
Non-Student
Name of Individual: Location of Incident (School):
Age: DOB: M F Spanish/Hispanic/Latino: Yes No African American White Asian Am. Indian/Alaskan Native Hawaiian/Other Pacific Islander Other
History of severe or life-threatening allergy: Yes No If known, specify type of allergy: History of anaphylaxis: Yes No Previous epinephrine use: Yes No Diagnosis/history of asthma:Yes No If yes, was asthma rescue inhaler available and used? Yes No
Incident Date Time a.m. p.m. Trigger that precipitated the allergic episode, if known: Food Insect Sting Latex Medication Exercise Unknown If food was a trigger, specify which food: ______other: If food was a trigger, specify if food was: Ingested Touched Inhaled Unknown Other:
How did exposure occur?
Symptoms: (Check all that apply) Respiratory Gastro-Intestinal Skin Cardiac/Vascular Other Cough Abdominal discomfort Swelling Chest discomfort Diaphoresis Difficulty breathing Diarrhea Flushing Cyanosis Irritability Hoarse voice Difficulty swallowing General itching Dizziness Loss of consciousness Congestion/runny nose Mouth itching General rash Faint/Weak pulse Metallic taste Swollen (throat, tongue) Nausea Hives Headache Red eyes Shortness of Breath Vomiting Lip swelling Hypotension Sneezing High-pitched breathing Localized rash Tachycardia Tightness (chest, throat) Pale Wheezing
Epinephrine Administered: Classroom Cafeteria Health Room Playground PE Athletic Field Bus other: 1st dose of epinephrine given by: EMS School Nurse 1st Responder Coach/PE teacher Other: Time of 1st dose epinephrine: a.m. p.m. Time EMS notified: a.m. p.m. Was a 2nd dose of epinephrine required? Yes No Unknown If yes, time 2nd dose administered: a.m. p.m. 2nd dose administered by: EMS School Nurse 1st Responder Coach/PE teacher Other: Did rebound of symptoms occur (biphasic reaction)? Yes No Unknown Time EMS transported to ER: a.m. p.m. Hospitalized? Yes No Unknown
Form completed by (name/title): Date:
Attachment E/Anaphylaxis Protocol Original to Sherry Sullivan, Central Office. Copy to Carol Eatman, School Health Coordinator. Form reviewed by principal: Date: