| Document Date: 2011-06-22 15:22:55
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Country Canada / / IndustryTerm food allergies / injection site / food / / MedicalCondition anaphylactic reaction / severe allergic reactions / allergic reaction / hypertension / chest pain / headache / shortness of breath / hives / cardiac arrhythmias / ischemic heart disease / nausea / anaphylaxis / nasal congestion / cardiovascular disease / diabetes / itching / allergy / tremor / pain/cramps / vomiting / food allergies / angina pectoris / organic heart disease / restlessness / dizziness / cough / wheezing / asthma / / MedicalTreatment emergency treatment / allergen immunotherapy / / Organization Canadian Society of Allergy and Clinical Immunology Date Twinject / / / Position Patient/Parent/Guardian Signature Date Physician / physician / ER physician / / Product Epinephrine / Twinject / EpiPen / Egg Latex Milk Medication / / Technology cellular telephone / / URL www.twinject.ca / /
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Anaphylaxis Emergency Plan: _____________________________________________ (name) This person has a potentially life-threatening allergy (anaphylaxis) to: (Check the appropriate boxes.)