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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