Anaphylaxis Emergency Action Plan

IF IN DOUBT, GIVE EPINEPHRINE.

INCOMPLETE—Requires clinician review before use (Display this warning only if: allergens are unknown/blank, epinephrine dose is not selected, or fewer than one emergency contact is provided.)

Patient Information

• Patient Name: [Patient full name]
• Date of Birth: [MM/DD/YYYY]
• Photo: [Patient photo] (If no photo available, write "Photo not available.")
• Plan Date: [MM/DD/YYYY] | Review By: [MM/DD/YYYY]

Risk Summary & Known Allergens

Trigger Categories: (Check all that apply.)

• Food
• Insect sting
• Medication
• Latex
• Exercise-related
• Other: [Specify other triggers]
• Unknown

• Confirmed allergens: [List specific allergens] (If unknown, write "Unknown/idiopathic—verify with clinician.")
• Asthma: [Yes / No]
• History of anaphylaxis: [Yes / No]
• May self-carry and self-administer epinephrine: [Yes / No] (Include only for school/childcare plans.)

Epinephrine Information

• Device/Brand: [Device name]
• Dose strength: [0.1 mg / 0.15 mg / 0.3 mg] (Select one. If unknown, write "Unknown—confirm with prescribing clinician.")
• Number of devices: [Number]
• Location(s): [Where devices are kept]

How to give: Inject into the middle of the outer thigh. Can inject through clothing. Note the time given.

Recognize the Signs

Emergency Action Steps

If SEVERE symptoms or known serious exposure:

1. GIVE EPINEPHRINE immediately. Time given: ______
2. Call 911. Say "anaphylaxis" and request an ambulance.
3. Position the person: Lay flat on back. If vomiting or having trouble breathing, place on side. Do not let them stand or walk.
4. Second dose: Give another dose if symptoms worsen or do not improve after 5 minutes. Time given: ______
5. Give other prescribed medications (antihistamine, inhaler) only AFTER epinephrine. Never use instead of epinephrine.
6. Notify emergency contacts.

If MILD symptoms only:

• Stay with the person and monitor closely.
• Give antihistamine if prescribed.
• Contact parent/guardian.
• If symptoms progress or worsen: USE EPINEPHRINE and follow the severe steps above.

After Epinephrine

Symptoms can return even after improvement. Medical evaluation is needed. Bring used and unused devices to the hospital. Replace used devices promptly.

Emergency Contacts

• Contact 1: [Name] / [Relationship] / [Phone]
• Contact 2: [Name] / [Relationship] / [Phone]
• Treating Clinician: [Name] / [Phone]

Authorization

• Prescribing Clinician Signature: ______________________ | Date: [MM/DD/YYYY]
• Clinician Name/Credentials: [Printed name and credentials]
• Parent/Guardian Signature: ______________________ | Date: [MM/DD/YYYY] (Include if applicable.)