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FOOD ALLERGY ITALIAAssociazione Italiana Allergie Alimentari
Registro Associazioni di Promozione Sociale del Veneto N. PSPD0064Registro Associazioni di Promozione Sociale del Comune di Padova N. 1275
CO
PYR
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OD
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35121 PADOVA – Piazza de Gasperi, 45/A – www.foodallergyitalia.org – info@foodallergyitalia.org – +39 3402391230 – +39 0498761155In cooperation with the Referral Centre for Food Allergy, Veneto Region, Padua General University Hospital, Padua, Italy.
Name______________________________________________________
Surname____________________________________________________
Date and Place of Birth__________________________________________
Residence____________________________________________________
ASTHMA: YES NO
SYMPTOMS OF ALLERGIC REACTION:(at the simultaneous appearance of multiple symptoms proceed with the pharmacological intervention plan) MOUTH: swelling and itching of the lips and throat. THROAT: itching, irritating barking cough, hoarse voice. SKIN: localized or diffused hives or rash , swelling of the face or extremities. DIGESTIVE SYSTEM: nausea, abdominal cramp pain, repeated vomiting and/or diarrhea. RESPIRATORY SYSTEM: irritating barking cough, wheezing, breathing difficulty. CIRCULATORY SYSTEM: collapse. NEUROLOGICAL SYSTEM: lifelessness, feeling down, loss of consciousness.
FOOD ALLERGY AND ANAPHYLAXIS: ACTION PLAN IN CASE OF EMERGENCY
ABROAD
PREVIOUS ANAPHYLACTIC REACTION: YES NO
Others
ALLERGIC TO:
Cereals containing gluten Shellfish Egg Fish
Peanuts Soya Milk Treenuts
Patient Photo
high risk of developing
a severe allergic reaction
}
PHARMACOLOGICAL INTERVENTION PLANN.B. The lifesaving kit can be found 1. If symptoms are: ITCHING OF THROAT, SWOLLEN TONGUE AND LIPS, HIVES OR RASH, NAUSEA, ABDOMINAL CRAMP PAINS
Administer: ANTIHISTAMINE commercial name dosage expiry date (to be kept at room temperature and away from light) ANTIHISTAMINE ADMINISTERED AT: Date Time
Administer: BRONCHODILATOR commercial name dosage expiry date (to be kept at room temperature and away from light) BRONCHODILATOR ADMINISTERED AT: Date Time
FOOD ALLERGY ITALIAAssociazione Italiana Allergie Alimentari
Registro Associazioni di Promozione Sociale del Veneto N. PSPD0064Registro Associazioni di Promozione Sociale del Comune di Padova N. 1275
CO
PYR
IGH
T ©
BY
FO
OD
ALL
ERG
Y IT
ALI
A 2
004
– 20
16Tu
tti i
dirit
ti ris
erva
ti ®
. Il c
onte
nuto
di q
uest
a pu
bblic
azio
ne n
on p
uò e
sser
e rip
rodo
tto, i
n tu
tto o
d in
par
te, a
rchi
viat
o o
diffu
so p
ubbl
icam
ente
, per
via
ele
ttron
ica
od a
mez
zo st
ampa
, fot
ocop
ia, m
icro
film
o
tram
ite q
uals
iasi
altr
o m
ezzo
, sen
za l’
espr
essa
aut
oriz
zazi
one
scrit
ta d
i FO
OD
ALL
ERG
Y IT
ALI
A.
35121 PADOVA – Piazza de Gasperi, 45/A – www.foodallergyitalia.org – info@foodallergyitalia.org – +39 3402391230 – +39 0498761155In cooperation with the Referral Centre for Food Allergy, Veneto Region, Padua General University Hospital, Padua, Italy.
3. Press firmly until you hear a click of activation. Leave in position for 10 seconds.
2. If symptoms progress (10-15 mins): HIVES WITH SWELLING OF THE FACE AND/OR HO-ARSE VOICE AND /OR BREATHING DIFFFICULTY AND /OR COLLAPSE Administer: SELF-INJECTABLE EPINEPHRINE phial mg commercial name expiry date (to be kept at room temperature and away from light)
INRUCTIONS FOR USE OF SELF-INJECTABLE EPINEPHRINE
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1 2
ii
2. Place the pen tip on the outer thigh.
4. Remove the pen.
1. Remove the colored cap.
if the person is unconscious, put he/she in recovery position according to the rules of first aid EPINEPHRINE ADMINISTERED AT: Date Time
Call the Emergency Number and inform:REFERENCE tel. REFERENCE tel. MEDICAL REFERENCE tel.
HAND OVER THE ADMINISTERED EPINEPHRINE TO THE FIRST AID PERSONNEL OR TO THE EMER-GENCY ROOM STAFF WHERE THE INDIVIDUAL HAS BEEN TAKEN FOR SUBSEQUENT OBSERVATION.
The two self-injectors avai-lable on the Italian market:
- Jext (on the left);- Fastjekt (on the right).
leave the person where he/she is and never alone, avoi-ding to keep him/her in upright position if the person is conscious put him/her in antishock po-sition, raising the legs up to facilitate the flow of blood to the head and heart. If the person has breathing difficulties (asthma) raise his/her upper body off the ground
PATIENT’S SIGNATURE:
ATTENDING PHYSICIAN’S SIGNATURE:
Date and Place: