Emergency Medical - Severe Allergy Form - Springer School and ...

EMERGENCY
MEDICAL AUTHORIZATION FORM
This form expires at the end of the current school year.
Student Name: Date of Birth: Home Phone:
Street Address: Apt # City: State: Zip:
Student Lives with:
Purpose: If a child becomes ill or is injured at Springer, we will make every reasonable attempt to contact the parents/guardians.
However, that is not always possible.
Parent/Guardian Information:
Mother’s Name:
First
Father’s Name:
First
Guardian’s Name:
First
Last
Last
Last
Phone:
Phone:
Phone:
Persons OTHER THAN Parents/Guardians to contact if Parents/Guardians CANNOT be reached:
Name:
Relationship to child:
Phone:
Address:
Name:
Relationship to child:
Phone:
Address:
**PART I OR II MUST BE COMPLETED**
I. TO GRANT CONSENT:
o In the event that injury or serious illness occurs when I cannot be contacted, I hereby authorize the school to call the
medical personnel listed for instructions or to make whatever arrangements are necessary.
PREFERRED PHYSICIAN: PHONE:
PREFERRED DENTIST: PHONE:
PREFERRED HOSPITAL: PHONE:
SIGNATURE OF PARENT/GUARDIAN
DATE
II.
REFUSAL TO CONSENT:
o I do NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring
emergency treatment, I wish the school authorities to take no action or to:
SIGNATURE OF PARENT/GUARDIAN
DATE
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CHRONIC ILLNESS/ALLERGY INFORMATION
** If Prescription Medication is required during school hours,
a separate form must be completed by the parent/guardian and physician**
Student’s Name: __________________________________Department:_____________ DOB: _____________
• CHRONIC ILLNESS ___ Yes ___ No
o Please Describe:_______________________________________________________________________________
o Precautions/Treatments during school hours__________________________________________________________
____________________________________________________________________________________________
• ASTHMATIC ___ Yes ___ No
o Inhaler Provided to School ___ Yes ___ No
• SEVERE ALLERGY ___ Yes ___ No
o SPECIFIC ALLERGY TO: ______________________________________________________________________
Allergy is: _______ Moderate ______Severe
Location of Allergy Meds ________________________________________________________________
Allergy History:
• Allergen: _______________________________________________________________________
• Past reactions due to (circle one): ingestion touch airborne
o TREATMENT:
Symptoms: Circle Medication to be administered (as authorized by physician):
• If a food allergen has been ingested, but no symptoms: Epinephrine Antihistamine
• Mouth: Itching, tingling, or swelling of lips, tongue, mouth Epinephrine Antihistamine
• Skin: Hives, itchy rash, swelling of face or extremities Epinephrine Antihistamine
• Gut: Nausea, abdominal cramps, vomiting, diarrhea Epinephrine Antihistamine
• Throat▲: Tightening of throat, hoarseness, hacking cough Epinephrine Antihistamine
• Lung▲: Shortness of breath, repetitive coughing, wheezing Epinephrine Antihistamine
• Heart▲: Weak or thready pulse, low blood pressure,
fainting, pale, blueness Epinephrine Antihistamine
• Other: Epinephrine Antihistamine
• If reaction is progressing give: Epinephrine Antihistamine
▲= Potentially life-threatening. The severity of symptoms can quickly change.
o Date of last anaphylactic reaction:
o DOSAGE:
Epinephrine: inject intramuscularly (circle one) EpiPen Jr. Twinject 0.3mg Twinject 0.15mg
Antihistamine: give medication/dose/route
OTHER: give medication/dose/route
o Physician’s Signature Date
**IMPORTANT**
Asthma inhalers and/or antihistamines cannot be depended on to replace epinephrine in anaphylaxis.
EMERGENCY TRANSPORT TO HOSPITAL IS MANDATORY
ANYTIME EPINEPHRINE HAS BEEN ADMINISTERED
• If your child felt unwell, would he/she seek help?______ If not, please comment:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
• Is there any other information you feel would be helpful for us to know about you child?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Parent’s/Guardian’s Signature___________________________________ Date______________________
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