<p> Report of Epinephrine Administration</p><p>Non-Student</p><p>Name of Individual: Location of Incident (School): </p><p>Age: DOB: M  F  Spanish/Hispanic/Latino: Yes  No  African American  White  Asian  Am. Indian/Alaskan Native  Hawaiian/Other Pacific Islander  Other </p><p>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 </p><p>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: </p><p>How did exposure occur? </p><p>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</p><p>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  </p><p>Form completed by (name/title): Date: </p><p>Attachment E/Anaphylaxis Protocol Original to Sherry Sullivan, Central Office. Copy to Carol Eatman, School Health Coordinator. Form reviewed by principal: Date: </p>