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)