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Allergen Exposure Plan

CONFIDENTIAL

Client Name

Date

PCP Name

PCP Phone

Known Allergens

Additional Allergies or Notes

Allergen #1 Name

Category (check all that apply)

Food Medical Other

Signs of Exposure (check all that apply)

Rash/Hives Swelling Trouble Breathing Anaphylaxis

Allergen #2 Name

Category (check all that apply)

Food Medical Other

Signs of Exposure (check all that apply)

Rash/Hives Swelling Trouble Breathing Anaphylaxis

Allergen #3 Name

Category (check all that apply)

Food Medical Other

Signs of Exposure (check all that apply)

Rash/Hives Swelling Trouble Breathing Anaphylaxis

EpiPen® Location

Where is the EpiPen® stored?

Note: The Direct Care Worker may retrieve the EpiPen for the client to self-administer if the client is unable to retrieve it themselves.

Complete Exposure Plan

Emergency Contact Name

Emergency Phone

Doctor Name

Doctor Phone

680 Lincoln Hwy, Fairless Hills, PA 19030 800-719-6912 [email protected]

Date:

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Helping seniors in Bucks and Philadelphia Counties stay independent in their own homes since 2016. We're here to help you live your best life at home.

Services

Personal Care
Companionship
Meal Preparation
Medication Reminders
Light Housekeeping
Transportation

Contact Us

680 Lincoln Hwy
Fairless Hills, PA 19030
800-719-6912
[email protected]
Mon-Fri: 8am-5pm

CHC Authorized Provider

UPMC Community HealthChoices

Keystone First

PA Health & Wellness