Anaphylaxis Action Plan (Red)

Action plans can only be ordered online if the patient has attended an appointment with Dr Falk within the last 18 months.

• Has the patient seen Dr Falk within the last 18 months? *

  •  Yes
  •  No

• Sorry, it has been too long. *

  		You need to have been reviewed by Dr Falk within 18 months to obtain an online action plan.
  		Please make an appointment. at your earliest convenience.

• Patient's Name *

• Date of Birth (dd/mm/yyyy) *

• What is the patient's current weight? *

• Education Level *

  •  Pre-school / Day Care
  •  Primary School (K-6)
  •  High School (7-12)

• List the allergens on the existing action plan. *

• What antihistamine and dose is on the existing action plan? *

• Does the patient have asthma? *

  •  No
  •  Yes