LIFE-THREATENING ALLERGYStudent name: DOB:School: Grade:THIS PORTION TO BE COMPLETED BY LICENSED HEALTHCARE PROVIDER (LHCP)Life-threatening severe allergy to:For the following symptoms Give the following medicationsFor individual symptoms, if multiple medications are selected, Epinephrine will always be given first.
❑ Albuterol Oral Inhaler puffs by mouth ❑ Other:
Inhale puffs orally once.
❑ Inhale puffs minutes prior to physical activity prn.
LHCP SIGNATURE/INFORMATI...
Allowed
Adobe Portable Document Format (.pdf) - application/pdf