Severe Allergy Action Plan  

Please only submit this form if your child has a severe allergy that will require a care plan and needs medication.

If you need to contact the medical centre to discuss email  medicalcentre@seaford.org or call extension 431

Name of Child: *
Date of Birth: *
Add Childs Passport Photo/ID

ALLERGY HISTORY

My Child has a SEVERE ALLERGY *
The SEVERE allergy is to:
My Child is also Allergic to:
(List all other mild allergies your child has that may need to take medication in school).
My Child has the following medication prescribed:
Please list any current medication your child is prescribed for Allergies:
Name of Medication, Dose and Expiry Date:



SYMPTOMS OF ALLERGY

When my child experiences an reaction the usual symptoms are:
Any other indication of imminent allergic reaction we should observe:

CARE PLAN IN EVENT OF A REACTION

When my Child experiences a reaction the following actions have been recommended:

Emergency Action 1 - 4

Action 1
Action 2
Action 3
Additional instructions:

If wheezy, GIVE ADRENALINE FIRST, then asthma reliever (blue puffer).

Other action to take:

In the event of a serious allergic reaction this further action has been advised by GP/Nurse
Allergy Care Plan:

Please attach any documents relating to you childs condition that you have from the Hospital or GP/Specialist Nurse:
In the event of an Emergency please contact: (1) *
Phone Number: *
In the event of an Emergency please contact: (2) *
Phone Number: *

PARENTAL CONSENT:

I hereby authorise the school staff to administer the medicines listed on this plan, when deemed necessary,  including the emergency use of a "spare" emergency back-up adrenaline autoinjector (AAI) if available, in accordance with Department of health Guidance on the use of AAI's in schools.

Name: *
Signature: *
Date: *

WATCH FOR SIGNS OF ANAPHYLAXIS (life-threatening allergic reaction)

MILD/MODERATE SIGNS/ ACTION TO TAKE

Dose regime in Children Cetirizine hydrochloride is not licensed for use in children under 2 years of age. A suggested dose regimen is: Children aged 2–5 years — 2.5 mg twice daily. Children aged 6–11 years — 5 mg twice daily. Children aged 12 and over, and adults — 10 mg once daily.

In a Medical Emergency call 999 if the Child/Adult is having difficulty breathing or appears unconscious.   


Please state  the address:    Seaford College, Lavington Park,  Petworth, GU28 0NB. 

And your Location on site:

In all cases of allergic reaction the Child should be assessed immediately by the School Nurse.  Please contact us on Extn 431 or 720 or the emergency mobile.


Thank you for completing the Care Plan.  Contact our School Nurses on 01798 867392 on Extension 431 or email us at medicalcentre@seaford.org if you would like to discuss your child's medical condition.  

Please leave the next box blank or your submission will not be accepted: