Allergies Information Form (1) Physician’s Orders: Student’s Name* First Last DOB (MM/DD/YYYY)Parent's NameParent’s Telephone Number (H)Telephone Number (W)What is your child allergic to?When and how many times did your child exhibit this allergic reaction? (Gives dates)Description of past allergic reactionWhat steps were taken at that time?Give name, address and telephone number of physician who has treated or is aware of this allergic reaction.Physician’s Orders:PHYSICIAN’S ORDERS: Epi-pen Jr. The above medication is to be given: Immediately (Do not wait for symptoms to begin) After the following symptoms occur: Apprehension Difficulty Breathing Flushing Hives Itching/Skin Burning Loss of Color Loss of Consciousness/Drowsiness Sneezing/Coughing Turning Blue Wheezing/Shortness of Breath Additional InstructionsFood Allergy & Anaphylaxis Emergency Care PlanClick here to download Allergy Special Care Plan Once you complete the Allergy Special Care Plan please upload it through the file upload option below:Upload Allergy Special Care Plan here Drop files here or Physician’s NamePhysician's AddressPhysician's Email Address Physician's Telephone NumberPhysician’s SignatureDate Date Format: MM slash DD slash YYYY
