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AUTHORIZATION OF EMERGENCY TREATMENT
(All Areas Must Be Completed)
________________________________________ is allergic to: ______________________
Allergic Reaction Risk Level: _____ Low _____ Moderate _____ High
If you suspect that a food allergen has been ingested (or insect sting), immediately determine the symptoms and treat the
reaction as follows:
Give Medication checked “X”
Itching, tingling, or swelling of lips, tongue, mouth
Hives, swelling on face or extremities, itchy rash
Nausea, abdominal cramps, vomiting, diarrhea
Tightening of throat, hoarseness, hacking cough
Shortness of breath, repetitive coughing, wheezing
Thready pulse, passing out, fainting, pale, blueness
Panic, sudden fatigue, chills, fear of impending doom
If a food allergen has been ingested, but no symptoms:
If a reaction is progressing (several of the above areas affected)
Medication Dosages: Nurses Only
Antihistamine: (liquid diphenhydramine, Benadryl™):
Give __________________________ Teaspoon(s) _______cc (_______mg) by mouth.
NURSE OR DELEGATE:
EpiPen™: Epi-Pen ______ Epi-Pen Jr. _____ (______mg) injected once into upper outer thigh
Epinephrine injection many need to be repeated if the child’s symptoms persist or get worse.
Call 911 and phone number: ________________________________
State that the child had a severe allergic reaction, and additional epinephrine doses may be needed.
Additional contact information:
__________ Phone: ______________ Address: _________________
Allergist Name: _____________________________ Phone: _________________________
Pediatrician Name: __________________________ Phone: __________________________
Parent’s Name (other contacts) and Contact Numbers:
Phone (1) ___________________________________ Phone (2) _______________________
Phone (1)_____________________________________Phone (2)
Other allergies, medication allergies, medical conditions: _______
Approximate Weight ____lbs.
DO NOT HESITATE TO ADMINISTER MEDICATION OR TAKE THE CHILD TO A MEDICAL FACILITY EVEN
IF THE PARENTS CANNOT BE REACHED!
This student may _____ may not _____ self-administer epinephrine auto injector.
Medication Located: _____ Nurse’s Office ______Classroom _____With Student_____Other (Specify)
Physician’s Printed Name Physician’s Signature
TRAINED DELEGATE _________________________________ Room #________________
Journal of Pharmaceutical and Biomedical Analysis 38 (2005) 781–784Stable isotopic composition of the active pharmaceuticalA.M. Wokovich , J.A. Spencer , B.J. Westenberger , L.F. Buhse , J.P. Jasper a Food and Drug Administration, Center for Drug Evaluation and Research, Division of Pharmaceutical Analysis, St. Louis, MO 63101, USA b Molecular Isotope Technologies, LLC, 8 Old Oak Lane, Nia
Featured in Highlander , April 2007 – Issue #88 Revealing new information about hormone therapy, cancer, and rescuing foals By Karolyn A. Gazella Premarin is a widely prescribed hormone replacement (HRT) drug. Premarin actually stands for pregnant mare urine. The process is methodical and brutal to the mares. After the mare is impregnated, she is confined to a small pen, a cat