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Epinephrine/Anaphylaxis Reports
CDE Health and Wellness / Report of Epinephrine Administration (2019-20) PLEASE answer each question
School District:
*
Name of School:
*
Date and time of occurrence
*
Student Age:
*
Does student have
a known allergy?
*
Yes
No
Don't know
Was an allergy
action plan available?
*
Yes
No
Diagnosis or History of Asthma:
*
Yes
No
Don't Know
If known, specify trigger that
precipitated this allergic episode:
*
Food
Insect Sting
Exercise
Medication
Latex
Inhaled
Unknown
Other (specify to the right)
If response was OTHER
from drop down menu
on the left, please explain.
If food was a trigger,
please specify which food:
*
Location where symptoms developed:
*
Off School Grounds
Classroom
Cafeteria
Health Office
Playground
Bus
Other (provide brief answer in the box to the right)
If response was OTHER
from drop down menu to the left,
please explain:
How was the incident triggered?
Please choose one from the following
drop down menu:
*
Ingested
Touched
Inhaled
Other (specify in box to the right)
If response was OTHER
from drop down menu to the left,
please explain:
Respiratory Symptoms
(check all that apply):
Respiratory
Cough
Respiratory
Difficulty breathing
Respiratory
Hoarse voice
Respiratory
Nasal congestion/runny nose
Respiratory
Swollen throat/and or tongue
Respiratory
Shortness of breath
Respiratory
Itching - mouth/throat
Respiratory
Tightness - chest/throat
Respiratory
Wheezing
Respiratory
Does not apply
Respiratory
GI Symptoms
(check all that apply):
GI
Abdominal discomfort
GI
Diarrhea
GI
Difficulty swallowing
GI
Nausea
GI
Vomiting
GI
Does not apply
GI
Skin Symptoms
(check all that apply):
Skin
Flushing
Skin
General itching
Skin
General rash
Skin
Hives
Skin
Lip Swelling
Skin
Localized rash
Skin
Pale
Skin
Does not apply
Skin
Cardiovascular Symptoms
(check all that apply):
Cardiovascular
Chest discomfort
Cardiovascular
Bluish skin
Cardiovascular
Dizziness
Cardiovascular
Weak pulse
Cardiovascular
Headache
Cardiovascular
Heart racing
Cardiovascular
Does not apply
Cardiovascular
Other Symptoms
(check all that apply):
Other
Sweating
Other
Irritability
Other
Loss of consciousness
Other
Metallic taste
Other
Red eyes
Other
Sneezing
Other
Does not apply
Other
Does your school have
stock epinephrine?
*
Yes
No
Auto-injector used
(choose one)
*
Student's
Stock (school)
Epinephrine administered by
(please choose one):
*
-
RN
School Staff
EMS
Parent
Self
Other (specify in box to right)
If response was OTHER
from drop down menu on the left,
please give a short answer regarding details (if this
does not apply, please type N/A):
Location where epinephrine was
administered (please choose one):
*
-
Health office
Classroom
Ambulance
Front/Main Office
Other (specify location in box to right)
-
If response was OTHER
from drop down menu on the left,
please give a short answer regarding details
Location of epinephrine storage
(please choose one):
*
Classroom
Student Self Carries
Health Office
Other (specify location in box to right)
If response was OTHER
from drop down menu on the left,
please give a short answer regarding details
Disposition:
Transferred to ER?
(Please choose one)
*
Yes (respond to question to right)
No
Don't know
If transferred,
how? (choose one)
*
Ambulance
Parent/Guardian
Other (specify to right)
If response was OTHER
from drop down menu
on the above, please give
a short answer regarding details
Was a second epi-pen
dose required?
*
Yes (respond to question on right)
No
Don't know
If response was yes,
was that dose
administered at the school
prior to arrival of EMS?
Yes
No
Don't know
Time elapsed between
communication of
symptoms and
administration of
epinephrine
*
Hours
Minutes
Time
Hours
Minutes
Form Completed By:
First Name
*
Last Name
*
Title:
*
Phone Number:
*
Date Form
Completed:
*
Email address:
*
Using your mouse, please place your signature in the box below:
*
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