To be completed by healthcare provider
School Nurse: Parent/Guardian’s Signature: policies Education of Board their with compliance in liability any from personnel and school the release and devices delivery/monitoring and medication prescribed with school the providing for responsibility full assume I provider. health our care contact pe school for permission give I of is capable and instructed been has Student DOSAGE Asthma: ____ HISTORY: Name: Student’s
ALLERGY TO: TO: ALLERGY School: _
agitation Confusion, happen, to about is bad something Feeling OTHER: com or severe (if diarrhea or Vomiting GUT: redness widespread body, over hives Many SKIN: dizzy pulse, weak faint, blue, Pale, HEART: S MOUTH: breathing/swallowing trouble hoarse, Tight, THROAT: cough repetitive wheeze, breath, of Short LUNG: SYMPTOMS: SEVERE Provider’s Signature: _ Pr 3. 2. 1.
SKIN: itch Amild hives, few NOSE: runnyItchy, nose, sneezing ONLY SYMPTOMS MILD ______If symptoms do not improve Asthma Rescue Inhaler Inhaler Rescue Asthma Antihistamine GUT: Mild nausea/discomfort ovider (print) _
a. Emergency contacts: Name/Relationship Parent: ______epinephrine, oxygen, or other medications may be needed. If epinephrine given, c b. ______Teacher: ______
: Colorado
Epinephrine ______1) ______1) ______2)______NO NO
YES Date: Date: ______
______
with other symptoms other with (h welling of the tongue and/or lips and/or tongue the of welling
: igher igher (brand and dose and (brand ______Allergy : inject intramuscularly inject using risk severe for reaction) – rsonnel to share this information, follow this plan, administer medication and care for my child and, if necessary, necessary, if and, child my for care and medication administer plan, this follow information, this share to rsonnel ______Date: ______Date: ______
Any of the following: the Anyof (brand and dose) and (brand
DO DO ____ and al :
l 911.l NOT HESITATE TO ADMINISTER EMERGENCY MEDICATIONS EMERGENCY ADMINISTER TO HESITATE NOT minutes or more
______Grade: ______D.O.B. ______
◊ STEP 2: EMERGENCY CALLS ◊ CALLS EMERGENCY 2: ◊ STEP State that an anaphylactic an that State
STEP 1: TREATMENT
refer to their asthma care plan care asthma their to refer
carrying and
, or symptoms return, 2
auto injector auto Emergency Care b
ined ined
Phone Number:
- self Phone Number(s)
____ (check one): administering
reaction has beentreated andadditional ______
nd 3. orders) Do not use other medicine in place of of place in medicine other use not Do orders) for below (see prescribed. if medicine, other Give 2. 1. 2. 2. 1. epinphrine
dose of epinephrine
Plan If If Stay with child and child with Stay
GIVE progress symptoms and follow directions in above box in above directions and follow
• • • and child with Stay • • 911 Call INJECT EPINEPHRINE IMMEDIATELY EPINEPHRINE INJECT • • ______mild more or two
_
______
______
Phone Number: ______
student put breathing, difficulty or vomiting If . down lying them keep student; Monitor below instructed as available if epi of dose second give worsen or improve don't symptoms If Cal Tell