Name of Individual: Location of Incident (School): Age: DOB: M 5 F 5 Spanish/Hispanic/Latino

Name of Individual: Location of Incident (School):
Age: DOB: M 5 F 5 Spanish/Hispanic/Latino: Yes 5 No 5

African American 5 White 5 Asian 5 Am. Indian/Alaskan Native 5 Hawaiian/Other Pacific Islander 5 Other
History of severe or life-threatening allergy: Yes 5 No 5 If known, specify type of allergy:

History of anaphylaxis: Yes 5 No 5

Previous epinephrine use: Yes 5 No 5

Diagnosis/history of asthma: Yes 5 No 5 If yes, was asthma rescue inhaler available and used? Yes5 No5

Incident Date Time a.m. 5 p.m. 5

Trigger that precipitated the allergic episode, if known: Food5 Insect Sting5 Latex5 Medication5 Exercise5 Unknown5
If food was a trigger, specify which food: ______other:

If food was a trigger, specify if food was: Ingested 5 Touched 5 Inhaled 5 Unknown 5 Other:
How did exposure occur?
Symptoms: (Check all that apply)

Respiratory Gastro-Intestinal Skin Cardiac/Vascular Other
5 Cough 5 Abdominal discomfort 5 Swelling 5 Chest discomfort 5 Diaphoresis
5 Difficulty breathing 5 Diarrhea 5 Flushing 5 Cyanosis 5 Irritability

5 Hoarse voice 5 Difficulty swallowing 5 General itching 5 Dizziness 5 Loss of consciousness

5 Congestion/runny nose 5 Mouth itching 5 General rash 5 Faint/Weak pulse 5 Metallic taste

5 Swollen (throat, tongue) 5 Nausea 5 Hives 5 Headache 5 Red eyes

5 Shortness of Breath 5 Vomiting 5 Lip swelling 5 Hypotension 5 Sneezing

5 High-pitched breathing 5 Localized rash 5 Tachycardia

5 Tightness (chest, throat) 5 Pale

5 Wheezing

Epinephrine Administered: Classroom5 Cafeteria5 Health Room5 Playground5 PE5 Athletic Field5 Bus5 other:

1st dose of epinephrine given by: EMS5 School Nurse5 1st Responder5 Coach/PE teacher5 Other:
Time of 1st dose epinephrine: a.m.5 p.m.5 Time EMS notified: a.m.5 p.m.5

Was a 2nd dose of epinephrine required? Yes 5 No 5 Unknown 5 If yes, time 2nd dose administered: a.m. 5 p.m. 5

2nd dose administered by: EMS5 School Nurse5 1st Responder5 Coach/PE teacher5 Other:

Did rebound of symptoms occur (biphasic reaction)? Yes 5 No 5 Unknown 5
Time EMS transported to ER: a.m. 5 p.m. 5 Hospitalized? Yes 5 No 5 Unknown 5

Form completed by (name/title): Date:

Form reviewed by principal: Date: