Free Action plan template 11
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Anaphylaxis Emergency Action Plan
Patient Name: ____________________________________________________________ Age: _______________
Allergies: ____________________________________________________________________________________
Asthma

Yes (high risk for severe reaction)

No

Additional health problems besides anaphylaxis: ___________________________________________________
_____________________________________________________________________________________________
Concurrent medications: _______________________________________________________________________
_____________________________________________________________________________________________
MOUTH
THROAT*
SKIN
GUT
LUNG*
HEART*

Symptoms of Anaphylaxis
itching, swelling of lips and/or tongue
itching, tightness/closure, hoarseness
itching, hives, redness, swelling
vomiting, diarrhea, cramps
shortness of breath, cough, wheeze
weak pulse, dizziness, passing out

Only a few symptoms may be present. Severity of symptoms can change q