Allergen Exposure Plan | Silver Home Care | Bucks & Philadelphia Counties

Allergen Exposure Plan

Complete this only if you have food or medication allergies. This plan helps keep you safe.

Important: Please keep this form updated whenever your allergies or emergency contacts change.

Known Allergens

Your Exposure Plan

Describe your personalized plan for managing allergens

Describe your exposure response plan:

Include steps you want caregivers to follow, where your medications are stored, and any other specific instructions.

Important: If the person has a history of severe allergic reaction (anaphylaxis) or shows signs of severe reaction (difficulty breathing, throat swelling, severe dizziness), call 911 immediately.

Our Commitments

We will never bring allergens into your home

We will wash hands before preparing food or medication

We will check labels on all food and products before use

We will keep your EpiPen/medications in the designated location you specify

We will communicate immediately if we suspect an allergic reaction

EpiPen / Epinephrine Auto-Injector

Do you have an EpiPen or epinephrine auto-injector?

Yes No

Where is the EpiPen kept?

Note: The direct care worker can retrieve the EpiPen if needed but is not permitted to administer it. Emergency medical services (911) must be called immediately in case of a severe allergic reaction.

Emergency Contacts

Emergency Contact #1 Name

Phone Number

Emergency Contact #2 Name

Phone Number

Primary Care Doctor

Doctor's Name

Doctor's Phone

Signature & Date

Printed Name

Date

Signature

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