JHCCB-E-1: Strategies in Prevention and Management of Anaphylaxis in the School Setting
Classification:
J: Students
Code:
JHCCB-E-1 APPENDIX A1
PHYSICIAN INFORMATION FORM FOR ANAPHYLAXIS
(Parent(s)/guardian(s) requests physician to complete and sign this form.)
Student Name:
Specific potentially life-threatening allergens:
The nature of the reaction. (Check all applicable.)
□ Physical contact with this allergen may cause an anaphylactic reaction.
□ Airborne contact with this allergen may cause an anaphylactic reaction.
□ Ingestion of food may cause an anaphylactic reaction.
□ Other (please explain below):
Recommended treatment in the event of accidental exposure:
Date: _________________________ ____________________________________
(Physician)
Date: _________________________
(This must be filed in the student’s record)
