Part 2: Life-Threatening Allergy Management Plan (LAMP) To Be Completed By Health Care Provider Valid for Current School Year ________________ Name: ___________________________________ DOB: ___________________ Allergy to: __________________________________________________________________ Asthma: No *High risk for severe reaction □yes □ no □ Asthma Action Plan It is medically necessary for student to carry epinephrine during school hours Yes No Signs of an Allergic Reaction Include: Systems: Symptoms:
Itching and swelling of the lips tongue or mouth
Itching and or a sense of tightness in the throat, hoarseness and hacking cough
Hives, itchy rash and/or swelling about the face or extremities
Nausea, abdominal cramps, vomiting, and/or diarrhea
Shortness of breath, repetitive cough and/or wheezing
*the severity of symptoms can quickly change. All the above symptoms can potentially progress to a life-threatening situation* Action for a Minor Reaction:
1. If ingestion is suspected and/or symptom(s) are: minor itching “and/or” mild hives to skin give:
Liquid Benadryl (or generic dephenhydramine) Dose:______________________ by mouth now and every 4-6 hours as needed.
2. Call Mother at _____________________ Father at _________________ or emergency contact. 3. Call Dr. _____________ at ___________________ to make physician aware of child’s reaction.
If condition worsens or does not improve within 10 minutes follow steps for MAJOR Reaction below: Action for a Major Reaction: 1. If symptom(s) are large amount of hives, throat swelling, cough, difficulty breathing, wheezing, vomiting, diarrhea or if symptoms progress after Benadryl is given, give:
-Epinephrine: inject intramuscularly: (check below)
Epipen® Epipen® Jr Twinject ™ 0.3mg Twinject ™ 0.15mg
-Liquid Benadryl: dose: ____________ every 4-6 hours as needed (if able to tolerate liquids) -Albuterol /or quick relief inhaler: 2 puffs with spacer now (IF asthmatic) Give above now then call:
2. CallRESCUE SQUAD 911 ASK FOR ADVANCED LIFE SUPPORT 3. Repeat dose of Epinephrine if no improvement in 5-10 minutes 4. Call Mother at _____________________ Father at _________________ or emergency contact. 5. Call Dr. _____________ at _______________ to make physician aware of child’s reaction. ________________________ _________ _________________________ _________ PARENTSSIGNATURE DOCTOR’S SIGNATURE Print MD Name: ___________________________________ Address: ___________________________________ Part 3: Life-Threatening Allergy Management Plan (LAMP)
Permission to Carry and/or Self-Administer Epinephrine (if appropriate)
Name: _________________________________ DOB: __________________________ I, as the Healthcare Provider, certify that this child has a medical history of severe allergic reactions has been
trained in the use of the prescribed medication(s) and is judged to be capable of carrying and self-administering this medication(s). The nurse or the appropriate school staff should be notified anytime the medication/injector is used. This child understands the hazards of sharing medications with others and has agreed to refrain from this practice.
_________________________________ ________________________________ ____________ Healthcare Provider Signature Print Healthcare Provider name Date
In accordance with the Code of Virginia Section 22.1-274, I agree to the following: I will not hold the school board or any of its employees liable for any negative outcome resulting from the
self-administration of said emergency medication by the student.
I understand that the school, after consultation with the parent(s) may impose reasonable limitations or
restrictions upon a student’s possession and/or self-administration of said emergency medication relative to the age and maturity of the student or other relevant consideration.
I understand that the school may withdraw permission to possess and self-administer the said emergency
medication at any point during the school year if it is determined the student has abused the privilege of possession and self-administration or that the student is not safely and effectively self-administering the medication.
Journal of Vestibular Research 17 (2007) 1–8Effects of fluvoxamine on anxiety,depression, and subjective handicaps ofchronic dizziness patients with or withoutneuro-otologic diseasesArata Horii ∗ , Atsuhiko Uno, Tadashi Kitahara, Kenji Mitani, Chisako Masumura, Kaoru Kizawa andTakeshi Kubo Department of Otolaryngology, Osaka University School of Medicine, Osaka, Japan Abstract . A prospe
Declaración de Principios 3.0 Las tres principales creencias del Partido Pirata son la necesidad de protección de los derechos de los ciudadanos, la voluntad de liberar nuestra cultura, y el entendimiento de que las patentes y los monopolios privados están dañando a la sociedad. La nuestra es una sociedad controlada y bajo vigilancia donde prácticamente todo el mundo está registrado y e