Allergy Information Sheet Student’s Name:________________________________

Grade:___________

Date: ___________

Type of Allergies: Check all that apply and list specifics. ! Medication: _________________________________________________________________________ ! Food:______________________________________________________________________________ ! Insect Bites/Stings:___________________________________________________________________ ! Environmental Allergens:______________________________________________________________ Symptoms of Allergy: check all that apply. ! Hives

! Shock

! Swelling of ____________________

! Fainting or dizziness

! Difficulty breathing

! Difficulty swallowing

! Other _____________________________________________________________________________ Treatment Is medication required immediately after exposure to the allergy producing substance? ! Yes

! No

Dosage: Epinephrine: (circle one)

Epipen®

EpiPen Jr.®

Twinject ® 0.3 mg

Twinject® 0.15 mg

Antihistamine:____________________________________________________________ Other:___________________________________________________________________ If yes, please check the appropriate treatment for each symptom: !

Mouth: itching, tingling, 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, coughing

! Epinephrine ! Antihistamine

!

Lung: Shortness of breath, wheezing, repetitive coughing

! Epinephrine ! Antihistamine

!

Heart: Weak or thready pulse, low blood pressure, fainting, ! Epinephrine ! Antihistamine pale, blueness.

!

Other:__________________________________________ ! Epinephrine ! Antihistamine

Has your child ever used the Epipen? ________________________________________________________ If no medication is necessary, how should the school treat the allergic event? ______________________________________________________________________________________!

Signature of parent/guardian:_______________________________

Date:_______________

Asthma Information Sheet

Student’s Name:________________________________ Grade:___________

Date: ________________

Physician treating child’s asthma: __________________________________Phone:__________________ Approximately how often does your child have an asthma attack? ________________________________ When was the last attack?

________________________________

Asthma Symptoms: Do any of the following trigger an asthma attack in your child: ! Exercise

! Strong odors or perfumes

! Respiratory infections

! Chalk dust

! Changes in temperature/weather

! Carpeting

! Animals

! Pollens

! Food __________________

! Molds

! Other:________________________________________________________________ Can your child identify early warning signs of an asthma attack?

! Yes

! No

If yes, please describe signs.________________________________________________________ Treatment Does your child routinely use an inhaler before exercise?

! Yes

! No

Does your child routinely use an inhaler or other preventative medications?

! Yes

! No

If yes, does your child use a spacer or holding chamber with his/her inhaler?

! Yes

! No

Does you child have side effects from these medications?

! Yes

! No

If yes, please explain.

__________________________________

Does your child understand asthma and what he/she should do to manage the condition?

! Yes

! No

!""#$#%&'()*%++,&$-.)___________________________________________________________ Signature of parent/guardian:________________________________

)

Date:_______________

Diabetes Information Sheet Student’s Name:________________________________

Grade:___________

Physician treating child’s diabetes:_________________________________

Date: ________________ Phone:________________

Date of Diagnosis:________________________ Diabetes Symptoms: !"#$%&"'()"*"+,-./," of high blood glucose (over ___________ mg/dl) & &

&&&&&&&&

! Increased thirst, urination, appetite&&

! Blurred vision

! Tiredness/sleepiness

! Warm, dry or flushed skin

! Glazed over eyes

! Fruity breath

&

! Other___________________________ Usual signs/symptoms of low blood glucose (under ___________ mg/dl) ! Hunger

! Change in personality/behavior

! Paleness

! Weak/shaky

! Tired/sleepy

! Dizzy/staggering

! Headache

! Rapid heart rate

! Nausea/no appetite

! Sweating

! Blurred vision

! Confusion

! Slurred speech

! Loss of consciousness

! Seizure

! Other

Blood Glucose Monitoring

&

Can you child recognize their symptoms of hyper/hypoglycemia?

! Yes

! No

Can your child ordinarily perform his/her /0)&1%//2&(%#3/"4&35436"7

! Yes

! No &

Can your child interpret the results?

! Yes

! No

Time blood glucose levels are to be checked: ! Before breakfast

! Before PE/Activity time

! Midmorning before snacks

! After PE/Activity time

! Before lunch

! Mid-afternoon

! Before 3:00p.m. dismissal

! Two hours after meals

! As needed

! Other _____________________

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