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 _____________________