|
Date of Inj
|
Extract
|
|
Dose
|
Dilution
|
|
Date of Inj
|
Extract
|
|
Dose
|
Dilution
|
|
Time of reaction
|
Patient waited 20-30 Min after injection?
|
|
Symptoms/Initial Exam
|
|
|
VITAL SIGNS
|
|
|
TIME
|
B/P
|
|
PULSE
|
RESP
|
|
PF
|
DR'S NOTES
|
|
TIME
|
B/P
|
|
PULSE
|
RESP
|
|
PF
|
DR'S NOTES
|
|
TIME
|
B/P
|
|
PULSE
|
RESP
|
|
PF
|
DR'S NOTES
|
|
TIME
|
B/P
|
|
PULSE
|
RESP
|
|
PF
|
DR'S NOTES
|
|
TREATMENT
|
|
|
ADRENALIN: TIME
|
ADRENALIN: DOSE
|
|
ADRENALIN: TIME
|
ADRENALIN: DOSE
|
|
ADRENALIN: TIME
|
ADRENALIN: DOSE
|
|
SUSPHRINE:TIME
|
SUSPHRINE:DOSE
|
|
ANTIHISTAMINE: TIME
|
ANTIHISTAMINE: DOSE
|
|
OTHER: TIME
|
OTHER: DOSE
|
|
O2 TIME
|
O2 LITERS
|
|
NEBULIZATION: TIME
|
NEBULIZATION: DOSE
|
|
MEDICATION
|
MEDICATION
|
|
FOLLOW-UP INSTRUCTIONS
|
FOLLOW-UP PHONE CALL
|
|
ATTENDING PHYSICIAN
|
|
