Oakdale swim team allergy medical action plan

Asthmatic      ☐ YES ☐ NO   If a food allergen has been ingested, but no symptoms ☐Observe  for  symptoms      ☐Epinephrine      ☐Antihistamine      ☐Albuterol Observe for Symptoms: Number  order  of  Medication  
Itching,  tingling  or  swelling  of  lips,   _  Epinephrine  _  Antihistamine  _  Albuterol   Hives,  itchy  rash,  swel ing  of  the  face  or   _  Epinephrine  _  Antihistamine  _  Albuterol   Nausea,  abdominal  cramps,  vomiting,   _  Epinephrine  _  Antihistamine  _  Albuterol   Tightening  of  throat,  hoarseness,  hacking   _  Epinephrine  _  Antihistamine  _  Albuterol   Shortness  of  breath,  repetitive  coughing,   _  Epinephrine  _  Antihistamine  _  Albuterol   Weak  or  thready  pulse,  low  blood   _  Epinephrine  _  Antihistamine  _  Albuterol   pressure,  fainting,  pale,  blueness   _  Epinephrine  _  Antihistamine  _  Albuterol   Epinephrine:  Inject  into  thigh  (circle  one):  EpiPen®  EpiPen®  Jr.  Twinject®  0.3  mg  Twinject®  0.15  mg   Antihistamine: Give________________________________________________________________ Albuterol: Give________________________________________________________________ Other: Give______________________________________________________________________ ✚  Administer  rescue  medication  as  prescribed  above    ✚ Stay  with  child  ✚  Contact  parents/guardian      IF THIS HAPPENS ✜  Hard  time  breathing  with:     GET EMERGENCY HELP
✜  Chest  and  neck  pulled  in  with  breathing  ✜  Child  is  hunched  over   ✜  Child  is  struggling  to  breathe   ✜  Trouble  walking  or  talking  ✜  Stops  playing  and  can’t  start  activity  again   ✜  Lips  and  fingernails  are  gray  or  blue    
Child’s  Name:  
(to be completed by Health Care Provider)  
Medications for Allergy
For children requiring rescue medication, the medication is required to be at program site at al times while
child is in care. For youth who self-medicate and carry their own medications, medication must be with the
youth at al times. The options of storing “back up” rescue medications at program is available.  
Travel Procedures
Rescue medications should accompany child during any off-site activities.
· The child should remain with staff or parent/guardian during the entire field trip. □ Yes □ No
· Staff members on trip must be trained regarding rescue medication use and this health care plan.
This plan must accompany the child on the field trip.
· Other (specify)_________________________________________________________________________
Self-Medication for Youth
YES. Youth can self-medicate. I have instructed _______________________in the proper way to use
his/her medication. It is my professional opinion that he/she SHOULD be allowed to carry and self
administer his/her medication. Youth has been instructed not to share medications and should youth violate
these restrictions the privilege of self medicating wil be revoked and the youth’s parents notified. Youth are
required to notify staff when carrying medication.
NO. It is my professional opinion that _______________________SHOULD NOT carry or self administer
his/her medication.  
Parental Permission/Consent
Parent’s signature gives permission for child/youth personnel who have been trained in medication
administration to administer prescribed medicine and to contact emergency medical services if necessary. I
also understand my child must have required medication with him/her at all times when in attendance.
Youth Statement of Understanding
I have been instructed on the proper way to use my medication. I understand that I may not share
medications and should I violate these restrictions, my privileges may be restricted or revoked, my parents
wil be notified and further disciplinary action may be taken. I am also required to notify staff when carrying
Follow Up
This Al ergy Medical Action Plan wil be updated/revised whenever medications or child’s health status changes. If
there are no changes, the Al ergy Medical Plan wil be updated at least every 12 months.
I agree with the plan outlined above.
Printed  Name  of  Parent/Guardian     Printed  Name  of  Youth  (if  applicable)     Stamp  of  Health  Care  Provider     Health  Care  Provider  Signature    

Source: http://www.oakdaleswimteam.com/recmvslog/UserFiles/File/Oakdale%20Swim%20Team%20Allergy%20Medical%20Action%20Plan.pdf


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