Name: _________________________________________________________________________ D.O.B.: ____________________
Allergy to: __________________________________________________________________________________________________
Weight: ________________ lbs.
Asthma: [ ] Yes (higher risk for a severe reaction) [ ] No
PLACE
PICTURE
HERE
1. Antihistamines may be given, if ordered by a
healthcare provider.
2. Stay with the person; alert emergency contacts.
3. Watch closely for changes. If symptoms worsen,
give epinephrine.
PATIENT OR PARENT/GUARDIAN AUTHORIZATION SIGNATURE DATE PHYSICIAN/HCP AUTHORIZATION SIGNATURE DATE
FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 4/2017
1. INJECT EPINEPHRINE IMMEDIATELY.
2. Call 911. Tell emergency dispatcher the person is having
anaphylaxis and may need epinephrine when emergency
responders arrive.
• Consider giving additional medications following epinephrine:
» Antihistamine
» Inhaler (bronchodilator) if wheezing
• Lay the person flat, raise legs and keep warm. If breathing is
difficult or they are vomiting, let them sit up or lie on their side.
• If symptoms do not improve, or symptoms return, more doses of
epinephrine can be given about 5 minutes or more after the last dose.
• Alert emergency contacts.
• Transport patient to ER, even if symptoms resolve. Patient should
remain in ER for at least 4 hours because symptoms may return.
HEART
Pale or bluish
skin, faintness,
weak pulse,
dizziness
MOUTH
Significant
swelling of the
tongue or lips
OR A
COMBINATION
of symptoms
from different
body areas.
LUNG
Shortness of
breath, wheezing,
repetitive cough
SKIN
Many hives over
body, widespread
redness
GUT
Repetitive
vomiting, severe
diarrhea
NOSE
Itchy or
runny nose,
sneezing
MOUTH
Itchy mouth
SKIN
A few hives,
mild itch
GUT
Mild
nausea or
discomfort
THROAT
Tight or hoarse
throat, trouble
breathing or
swallowing
OTHER
Feeling
something bad is
about to happen,
anxiety, confusion
Epinephrine Brand or Generic: ________________________________
Epinephrine Dose: [ ] 0.15 mg IM [ ] 0.3 mg IM
Antihistamine Brand or Generic: _______________________________
Antihistamine Dose: __________________________________________
Other (e.g., inhaler-bronchodilator if wheezing): __________________
____________________________________________________________
MEDICATIONS/DOSES
SEVERE SYMPTOMS
MILD SYMPTOMS
FOR MILD SYMPTOMS FROM MORE THAN ONE
SYSTEM AREA, GIVE EPINEPHRINE.
FOR MILD SYMPTOMS FROM A SINGLE SYSTEM
AREA, FOLLOW THE DIRECTIONS BELOW:
FOR ANY OF THE FOLLOWING:
NOTE: Do not depend on antihistamines or inhalers (bronchodilators) to treat a severe reaction. USE EPINEPHRINE.
Extremely reactive to the following allergens: _________________________________________________________
THEREFORE:
[ ] If checked, give epinephrine immediately if the allergen was LIKELY eaten, for ANY symptoms.
[ ] If checked, give epinephrine immediately if the allergen was DEFINITELY eaten, even if no symptoms are apparent.