Health History Information: Anaphylaxis
Since you selected “Yes” under Anaphylaxis on the Participant Online Enrollment form, we ask that you complete this form in consultation with your participant and his/her/their physician. Please submit form no later than May 1st.
If you have questions or concerns, please email (firacres@lclark.edu) or call us at 503-768-7932 and we will do our best to answer your questions.
Participants with multiple anaphylactic responses should complete one form for each allergen.
Participants who experience anaphylactic responses to allergens are likely to have symptoms that can change quickly and can potentially progress to a life-threatening situation.
Our expectation is that participants with anaphylactic responses are primarily responsible for recognizing their symptoms and self-administering injectable epinephrine (using an EpiPen®) when necessary. Participants should bring at least one EpiPen®, carry that device on his/her person throughout the Workshop, and know how to use it. Workshop staff may be able to help administer an EpiPen®, and will be able to arrange emergency transport to a nearby hospital (approximately 15 minutes away) if needed.
You may attach additional information as necessary, including medication orders and details about your participant’s anaphylaxis history.
We thank you for helping us plan your Workshop by filling out this important form. The more information we know about you before you arrive, the better your experience will be once you arrive in Portland.
Anaphylaxis Response Plan
Recognizing a Reaction
We expect the participant to tell a staff member if he/she suspects an allergic reaction.
Treating an Allergic Reaction
- If breathing is compromised, participant should immediately self-administer the EpiPen® as previously instructed by his or her health care professional. Staff will help administer the EpiPen® if needed.
- Workshop staff will call 911 and tell the paramedics that this is an anaphylaxis situation.
- If participant is breathing, staff will administer 50 mg diphenhydramine (e.g., Benadryl) by mouth, and remove participant from contact with allergen if possible.
- Staff will contact participant’s emergency contact listed here.
If your physician wants a different protocol followed, please have them write it legibly, sign and date it, and attach it at the bottom of this page. Please upload a PDF file.
All fields marked with asterisk (*) are required.