Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Allergy Action Plan Form Template

Ensure Safety with a Personalized Allergy Action Plan

An unexpected allergic reaction can be life-threatening, making it crucial to have a well-structured action plan. This Allergy Action Plan Form Template is designed for healthcare providers who want to create personalized strategies to protect their patients from allergens. With this template, you can easily outline emergency procedures, record medication instructions, and communicate important allergy information, ensuring everyone is informed and prepared. Plus, it offers WCAG-aligned labels for accessibility. Explore the live template today to enhance your patient care!

Use this Template (FREE) Live Preview
Full name of patient
Date of birth
Weight category for dosing
Under 25 kg (55 lb)
25 kg (55 lb) or more
Not sure
Prefer not to say
Known allergens
Please Specify:
If Other allergens, please specify
Usual early symptoms during a reaction
Please Specify:
Has the patient ever had a severe reaction requiring epinephrine or emergency care?
Yes
No
Has the patient been diagnosed with asthma?
Yes
No
Prescribed epinephrine auto-injector
Yes
No
Prescribed epinephrine dose
0.1 mg
0.15 mg
0.3 mg
0.5 mg
Not prescribed
Not sure
Location of epinephrine (home/school/work)
Antihistamine name and dose (if prescribed)
Bronchodilator/inhaler prescribed (for breathing symptoms)
Yes
No
Instructions for mild symptoms (one body system involved)
Instructions for severe symptoms or multiple body systems
If symptoms persist, a second epinephrine dose may be given after
5 minutes
10 minutes
15 minutes
20 minutes
As directed by emergency services
Not applicable / Do not repeat
After giving epinephrine, also do the following
Call emergency services
Lay person flat and raise legs unless breathing is difficult
Use inhaler if prescribed for breathing symptoms
Monitor breathing and be ready to start CPR
Contact the emergency contact listed
Do not give food or drink
Bring used auto-injector to medical staff
Other
Please Specify:
Primary contact full name
Relationship to patient
Self
Parent
Guardian
Spouse or partner
Relative
Caregiver
Other
Please Specify:
Primary contact phone
Secondary contact full name
Secondary contact phone
Primary healthcare provider name
Primary healthcare provider phone
Staff are authorized to administer epinephrine and other listed medications as ordered
Yes
No
Storage location of medications at site (if applicable)
Patient may self-carry/self-administer epinephrine if trained
Yes
No
Signature of patient or legal guardian
Date of signature
I confirm the information provided is accurate and consent to share this plan with caregivers and providers
Yes
No
{"name":"Full name of patient", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full name of patient, Date of birth, Weight category for dosing","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration representing an Allergy Action Plan form template for FormCreatorAI

When to use this form

Use this form when a student, patient, or employee has a diagnosed allergy and multiple people may need to respond fast. School nurses can set clear steps for teachers and coaches; parents can share the same plan with babysitters and camps. Clinicians can pair it with a Clinical assessment form to capture history and testing, and attach a Medical report form when formal documentation is required. If food triggers are unclear, connect it with a Food diary form to spot patterns over a few weeks. The result: everyone knows symptoms to watch, medications to give, and who to call, reducing confusion during an emergency.

Must Ask Allergy Action Plan Questions

  1. Which allergens trigger your reactions, and how were they confirmed?

    Naming exact allergens avoids guesswork and prevents exposure. Confirmation by skin test, blood test, or clear history lets responders trust the plan.

  2. What early and severe symptoms should prompt action?

    Listing early signs helps people act before symptoms escalate. Clear severe indicators, like breathing trouble or throat tightness, tell them to give epinephrine now.

  3. Where is your epinephrine auto-injector stored, and how many doses are available?

    Location and quantity save critical seconds. Knowing device type and expiration reduces errors during stress.

  4. What step-by-step actions should helpers take for mild versus severe reactions?

    A simple sequence reduces hesitation and mixed instructions. Include dosing, timing, and when to call emergency services.

  5. Who should be contacted in an emergency, and which hospital or clinic should you use?

    Names, roles, and direct numbers speed coordination and handoffs. This also aligns with employer or insurer records captured in a Statement of health form.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel