ASTHMA INFORMATION SHEET Name of student Name of parent/guardian School Year Grade Asthma Management Date or age of diagnosis Name of current physician Office number Please list ALL current medications, the dosages, and times of administration Which medications, if any, will need to be given during school hours? Do your child s medications stay at school? Yes Are your child s medications shared between home and school? Yes If applicable, does day care have medications available? Yes Does your child use a spacer with any of his inhaled medications? Yes Does your child cough daily? Yes Does your child have symptoms more than twice a week? Yes Do episodes of asthma occur at a particular time of the day or night? Yes If yes, please explain: How often has your child needed urgent care from a doctor for asthma in the past 12 months? In the past 3 months? Page 1 of 5
Known triggers for your child s asthma: (Please check all that apply) Respiratory infections/colds/flu Emotional stress/excitement Tree pollens Grass Flowers Mold House dust Weather changes Animal dander Exercise Strong odors Tobacco smoke Perfume Aerosol sprays Art projects with chalk, glue, fumes Other Foods (Please list) Does eating a meal ever seem to make your child s asthma worse? Yes Early signs of an asthma episode: (Please check all that apply) Coughing Wheezing Breathing open-mouthed Runny nose Shortness of breath Rapid breathing Fatigue Other Verbal complaints of: (Please check all that apply) Chest tightness Chest pain Can t catch a breath Mouth is dry Neck feels funny/itchy Complains of not feeling well Other Should your child pre-treat with medication prior to PE, sports, recess? Yes Does your child need assistance or monitoring during inhaler use? Yes How long should your child wait between puffs before another inhalation? Will your child carry his/her inhaler(s) on his/her person? Yes Are the proper forms on file in the clinic? Yes Are duplicate emergency supplies available in the clinic if the child will self-medicate? Yes Page 2 of 5
Peak Flow Monitoring Does your child use a peak flow meter? Yes If yes, what is his/her current GREEN zone? (Asthma is stable/under control. Full activity is permitted) What is his/her current YELLOW zone? (Becoming symptomatic. Usually means no strenuous activity or staying quiet) What is his/her current RED zone? (Usually requires being seen by physician/emergency room within one hour) School Schedule At approximately what time does your child arrive at school? Transported by: Bus # Day Care Private car Walker At approximately what time does your child leave school? Transported by: Bus # Day Care Private car Walker Are there restrictions for sports, PE, or recess? Yes If yes, please explain: How often does your child participate in sports/pe? Healthcare Action Plan If my child begins to show signs/symptoms of asthma, such as or has a peak flow reading of, the school shall: Notify the parent(s)? Yes Give medication(s)? Yes If yes, please specify: Improvement should be seen in minutes. Page 3 of 5
My child may return to class if: Emergency Action Plan Emergency asthma medications: School personnel shall seek emergency medical care if my child has any of the following signs/symptoms: (Please check all that apply) If there is no improvement 15-20 minutes after initial treatment and a parent/guardian cannot be reached. Peak flow of Chest/neck sucks in with each breath Nostrils are open wider than usual Hunching/lifting shoulders Child is struggling to breathe/making grunting sounds Trouble walking or talking Stops playing and can t resume activity Lips or nail beds are gray or bluish Extremely restless or sleepy Parent gives permission to call 911? Yes If yes, what is the hospital preference? Does your child have any drug allergies? Yes If yes, please list: Emergency Numbers (Please also indicate the relationship of the person to the student) lst person to call: Next or Alternate person(s) to call: Page 4 of 5
Additional Considerations Permission is hereby given to release this information to school personnel having need of such knowledge. Parent/Guardian signature: Date School employee signature: Date Page 5 of 5