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Page1of2ALLERGYACTIONPLAN
Students
Name:___D. O.B.___Gender:___
Parent/Guardian:___Grade:___Teacher:___
ALLERGY TO:___
PlaceChilds
Picturesque
Asthmatic:Yes×No*HigherriskforseverereactionTreatment
TobedeterminedbyhealthcareproviderauthorizingtreatmentLocationSymptomsGiveCheckedMedicationIfanallergenhasbeensuspectedbutnosymptomsarepresent
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