VERE SYMPTOM

Name:_________________________________________________________________________ D.O.B.: ____________________

Allergy to:__________________________________________________________________________________________________

Weight: ________________lbs. Asthma: [ ] Yes (higher risk for a severe reaction) [ ] No

PLACE PICTURE HERE

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.

SE^FOR ^ANY ^OF ^THE ^FOLLOWING: S

LUNG             HEART           THROAT          MOUTH Shortness of          Pale or bluish         Tight or hoarse           Significant
breath, wheezing, skin, faintness,        throat, trouble        swelling of the repetitive cough         weak pulse,             breathing or           tongue or lips
dizziness	swallowing

OR A COMBINATION
SKIN	GUT	OTHER	^of ^symptoms _Many _hives _over            _Repetitive                    _Feeling               from different
_body, _widespread	_vomiting, _severe	_something _bad _is	body areas.
redness	diarrhea	 about to happen, anxiety, confusion

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.

T
•	 ransport patient to ER, even if symptoms resolve. Patient should remain in ER for at least 4 hours because symptoms may return.

MILD SYMPTOMS

NOSE       MOUTH        SKIN           GUT Itchy or         Itchy mouth     A few hives,            Mild runny nose,                                   mild itch          nausea or
sneezing	discomfort

FOR MILD SYMPTOMS FROM MORE THAN ONE SYSTEM AREA, GIVE EPINEPHRINE.

FOR MILD SYMPTOMS FROM A SINGLE SYSTEM AREA, FOLLOW THE DIRECTIONS BELOW:

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.

MEDICATIONS/DOSES 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): __________________

____________________________________________________________

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

^HOW ^TO ^USE ^AUVI-Q® ^(EPINEPHRINE ^INJECTION, ^USP), ^KALEO	3 1. Remove Auvi-Q from the outer case.
2. Pull off red safety guard.
3. Place black end of Auvi-Q against the middle of the outer thigh. 4. Press firmly, and hold in place for 5 seconds.
5. Call 911 and get emergency medical help right away.

HOW TO USE EPIPEN^® AND EPIPEN JR^® (EPINEPHRINE) AUTO-INJECTOR, MYLAN 1. Remove the EpiPen^® or EpiPen Jr^® Auto-Injector from the clear carrier tube.
2. Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward. 3. With your other hand, remove the blue safety release by pulling straight up.
4. Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’. 5. Hold firmly in place for 3 seconds (count slowly 1, 2, 3).
6. Remove and massage the injection area for 10 seconds. 7. Call 911 and get emergency medical help right away.

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HOW TO USE EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF EPIPEN^®), USP AUTO-INJECTOR, MYLAN 1. Remove the epinephrine auto-injector from the clear carrier tube.
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2. Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward. 3. With your other hand, remove the blue safety release by pulling straight up.
4. Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’. 5. Hold firmly in place for 3 seconds (count slowly 1, 2, 3).
6. Remove and massage the injection area for 10 seconds. 7. Call 911 and get emergency medical help right away.

HOW TO USE IMPAX EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF ADRENACLICK^®), USP AUTO-INJECTOR, IMPAX LABORATORIES
1. Remove epinephrine auto-injector from its protective carrying case. 2. Pull off both blue end caps: you will now see a red tip.
3. Grasp the auto-injector in your fist with the red tip pointing downward.
4. Put the red tip against the middle of the outer thigh at a 90-degree angle, perpendicular to the thigh. 5. Press down hard and hold firmly against the thigh for approximately 10 seconds.
6. Remove and massage the area for 10 seconds.
7. Call 911 and get emergency medical help right away.

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ADMINISTRATION AND SAFETY INFORMATION FOR ALL AUTO-INJECTORS:
thigh. n case o accidental injection, go immediately to the nearest emergency room.
1. Do not_I put your _fthumb, fingers or hand over the tip of the auto-injector or inject into any body part other than mid-outer 2. If administering to a young child, hold their leg firmly in place before and during injection to prevent injuries.
3. Epinephrine can be injected through clothing if needed. 4. Call 911 immediately after injection.

OTHER DIRECTIONS/INFORMATION (may self-carry epinephrine, may self-administer epinephrine, etc.):

Treat the person before calling emergency contacts. The first signs of a reaction can be mild, but symptoms can worsen quickly.

EMERGENCY CONTACTS — CALL 911

RESCUE SQUAD: ______________________________________________________________________

DOCTOR: _________________________________________________ PHONE: ____________________

PARENT/GUARDIAN: ______________________________________ PHONE: ____________________

OTHER EMERGENCY CONTACTS

NAME/RELATIONSHIP: __________________________________________________________________

PHONE: _______________________________________________________________________________

NAME/RELATIONSHIP: __________________________________________________________________

PHONE: _______________________________________________________________________________

FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 4/2017