MEDICAL FORM - ASTHMA Insert Student Photo Here School Year 20 - 20 615 SNOW AVE. RICHLAND, WA 99352 MEDICAL FORM: ASTHMA (EMERGENCY CARE PLAN) Student’s Name: Date of Birth: School: Grade/Teacher: Emergency Treatment at School, unless otherwise indicated by Health Care Provider: Emergency Treatment Call 911 Remain calm; reassure student Chest/neck retracting with respiration Stay with student Student is hunched over Call the office or health room for the inhaler, or escort Student is struggling to breathe student to the health room - Do not send student alone Blue lips or fingernails Have student drink warm water Difficulty walking or talking Call parent & school nurse If improvement takes place, student may return to class No improvement 15 - 20 minutes after using inhaler AND parent cannot be after 15 minutes reached Other___________________________ No audible lung sounds Medical Provider to complete orders below: (please be specific and complete) No Is this a life-threatening condition for this student? Classroom Accommodations: Yes No Yes Remain inside during severe cold weather. Specify temp_________ No Yes Remain inside during severe windy/dusty weather. No Yes Participate in a group run, not to exceed ______ miles. No Yes Allow student to set own pace i.e. walk as needed. Other: ____________________________________________________________________ Medications to be administered at school for this condition Name of Medication (s) Dose Administer inhaler 15 minutes prior to PE: Time/Frequency (ie. Every 4 hrs as needed) No Yes Side effects of drug (if any) to be expected: Patient may may NOT keep medication on person & self-administer. Approved by School Nurse__________________________ RCW28.A210.370 Students with Asthma or Anaphylaxis -Please complete the following if this medication request pertains to a student who will self-administer medication for asthma or anaphylaxis at school. This student has demonstrated to a licensed health professional in my office the ability to correctly self-administer this medication (inhaler or automatic adrenalin device) and may carry the medication on his/her person Yes No This authorization is valid until the last day of school or : / /20 (not to exceed current school year) Health Care Provider Signature: Health Care Provider name (print or type): Phone: Fax: RSD Revised April 2014 Date: Address: MEDICAL FORM - ASTHMA PARENT TO FILL OUT How severe is your child’s asthma? Mild Moderate Severe Please mark the items which may trigger an asthma episode: Exercise Respiratory infections Change in temperature Animals Food: ___________ Strong odors or fumes Chalk dust Carpets Pollens Molds Other: Parent Permission: (to be completed by parent or guardian) Student: ________________________ Birth Date: _________ School: _______________ I request that my child be allowed to take medication as described. The medication is to be furnished by me in the original container, and BROUGHT TO SCHOOL BY AN ADULT. Prescription medication must be labeled by the pharmacy with the name of the patient, health care provider, medication, dosage, and the time of day to be given. I understand that my signature indicates my understanding that the school accepts no liability for untoward reaction when the medication is administered in accordance with the physician’s directions. I hereby authorize the exchange of confidential information regarding my child’s medication between the school nurse, and the above named physician. This authorization is good for the current school year only. Any change in medication or dose must be handled as a new medication, and a new form completed by both parent and health care provider. In case of necessity, the school district may discontinue administration of the medication with proper advance notice. I am the parent or the legal guardian of the child named. Signature of parent/guardian: ________________________________________ Date: __________________ Parent/Guardian Contact Information: *Please update your school office when contact information changes. Parent/Guardian #1: Phone (home) __________________(cell) _________________ (work)_______________ Parent/Guardian #1: Phone (home) __________________(cell) _________________ (work)_______________ Emergency Contacts (To be called if unable to reach parent) Name: _ ______ Relationship: _______________ (PH): ________________ (PH): ______ Name: _ ______ ______ Relationship: _______________ (PH): ________________ (PH): To Use a Spacer: 1. Shake the inhaler well before use (3-4 shakes) 2. Remove the cap from your inhaler and from your spacer (if it has one) 3. Put the inhaler into the spacer 4. Breathe out, away from the spacer 5. Bring the spacer to your mouth, put the mouthpiece between your teeth and close your lips around it 6. Press the top of your inhaler once 7. Breathe in very slowly until you have taken a full breath. If you hear a whistle sound, you are breathing in too fast. Slowly breathe in. Wait for ten seconds, then 8. Press the top of your inhaler again to administer the second puff Reviewed by school RN ___________________________________________ RSD Revised April 2014 Date _____________________