Name:__________________________________________________________________________ D.O.B.:_____________________
Allergy to:___________________________________________________________________________________________________
Weight:_________________ lbs. Asthma:

PLACEPICTURE
HERE□ Yes (higher risk for a severe reaction) □ No

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.

MILD SYMPTOMSFOR ANY OF THE FOLLOWING:

SEVERE SYMPTOMS
LUNG

HEART

Pale or bluish
Shortness ofbreath, wheezing, skin, faintness,
weak pulse,
repetitive coughdizziness

SKIN

Many hives overbody, widespread
redness

GUT

Repetitivevomiting, severe
diarrhea

THROAT

Tight or hoarse
throat, trouble
breathing orswallowing

OTHER

Feelingsomething bad is
about to happen,
anxiety, confusion

MOUTH

Significant
swelling of the
tongue or lips

OR A
COMBINATION
of symptoms
from different
body areas.

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

MOUTH

Itchy mouth

SKIN

A few hives,mild itch

GUTMildnausea ordiscomfort

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 ahealthcare provider.
3. Watch closely for changes. If symptoms worsen,
give epinephrine.

MEDICATIONS/DOSES
Epinephrine Brand or Generic: _________________________________
Epinephrine Dose:•Lay the person flat, raise legs and keep warm. If breathing isdifficult 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.

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

PATIENT OR PARENT/GUARDIAN AUTHORIZATION SIGNATURE

Itchy orrunny nose,sneezing

2. Stay with the person; alert emergency contacts.

1.

•NOSE

DATE

□ 0.1 mg IM □ 0.15 mg IM □ 0.3 mg IM

Antihistamine Brand or Generic:________________________________
Antihistamine Dose:___________________________________________
Other (e.g., inhaler-bronchodilator if wheezing): _______________________________________________________________________________PHYSICIAN/HCP AUTHORIZATION SIGNATURE

FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 5/2018

DATEHOW TO USE AUVI-Q® (EPINEPRHINE INJECTION, USP), KALEO
1.
2.
3.
4.
5.

3

Remove Auvi-Q from the outer case.
Pull off red safety guard.
Place black end of Auvi-Q against the middle of the outer thigh.
Press firmly until you hear a click and hiss sound, and hold in place for 2 seconds.
Call 911 and get emergency medical help right away.

HOW TO USE EPIPEN® AND EPIPEN JR® (EPINEPHRINE) AUTO-INJECTOR AND EPINEPHRINE INJECTION (AUTHORIZEDGENERIC OF EPIPEN®), USP AUTO-INJECTOR, MYLAN AUTO-INJECTOR, MYLAN
1.
2.
3.
4.
5.
6.
7.

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

3

HOW TO USE IMPAX EPINEPHRINE INJECTION (AUTHORIZED GENERIC OF ADRENACLICK®), USP
AUTO-INJECTOR, IMPAX LABORATORIES
1.
2.
3.
4.
5.
6.
7.

Remove epinephrine auto-injector from its protective carrying case.
Pull off both blue end caps: you will now see a red tip.
Grasp the auto-injector in your fist with the red tip pointing downward.
Put the red tip against the middle of the outer thigh at a 90-degree angle, perpendicular to the thigh.
Press down hard and hold firmly against the thigh for approximately 10 seconds.
Remove and massage the area for 10 seconds.
Call 911 and get emergency medical help right away.

45

HOW TO USE TEVA’S GENERIC EPIPEN® (EPINEPHRINE INJECTION, USP) AUTO-INJECTOR, TEVA PHARMACEUTICAL
INDUSTRIES
1.
2.
3.
4.
5.
6.
7.
8.

Quickly twist the yellow or green cap off of the auto-injector in the direction of the “twist arrow” to remove it.
Grasp the auto-injector in your fist with the orange tip (needle end) pointing downward.
With your other hand, pull off the blue safety release.
Place the orange tip against the middle of the outer thigh (upper leg) at a right angle (perpendicular) to the thigh.
Swing and push the auto-injector firmly into the middle of the outer thigh until it ‘clicks’.
Hold firmly in place for 3 seconds (count slowly 1, 2, 3).
Remove and massage the injection area for 10 seconds.
Call 911 and get emergency medical help right away.

5ADMINISTRATION AND SAFETY INFORMATION FOR ALL AUTO-INJECTORS:
1.

Do not put your thumb, fingers or hand over the tip of the auto-injector or inject into any body part other than mid-outer thigh. In case of
accidental injection, go immediately to the nearest emergency room.

2.
3.
4.

If administering to a young child, hold their leg firmly in place before and during injection to prevent injuries.
Epinephrine can be injected through clothing if needed.
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

OTHER EMERGENCY CONTACTSRESCUE SQUAD: _______________________________________________________________________

NAME/RELATIONSHIP:______________________________________ PHONE: _____________________

DOCTOR:__________________________________________________ PHONE: _____________________

NAME/RELATIONSHIP:______________________________________ PHONE: _____________________PARENT/GUARDIAN: _______________________________________ PHONE: _____________________

NAME/RELATIONSHIP:______________________________________ PHONE: _____________________FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) (FOODALLERGY.ORG) 1/2019