Tuloso-Midway ISD
Health Services
SCHOOL ASTHMA EMERGECNY ACTION PLAN
Student’s Name ______________________________________ Grade _____________
Date of birth ______________________________ ID# _________________________
Emergency Contact ________________________________________________
Phone: (H) ________________ (W) ___________________ (C) _________________
Doctor’s Name _________________________________ Phone __________________
USUAL ASTHMA ACTION PLAN
Usual signs of student’s asthma:
Wheezing
Tightness in chest
Coughing
Difficulty breathing
Difficulty speaking
 Yes
 Yes
 Yes
 Yes
 Yes
What triggers student’s asthma:
 No
 No
 No
 No
 No
Exercise
 Yes
 No
Colds/virus  Yes
 No
Allergies  Yes
 No
other triggers ______________
Worsening sings of student’s asthma:
Wheezing
Tightness in chest
Coughing
Difficulty breathing
Difficulty speaking
Medication
 Yes
 Yes
 Yes
 Yes
 Yes
 No
 No
 No
 No
 No
Asthma Medications
Dosage
School
Home
I give permission to my child’s school to administer emergency medications as necessary, in
accordance with the attached physician’s instructions.
Parent Signature ________________________________ Date ______________
TO BE COMPLETED BY PHYSICIAN
*********************Asthma Emergency Action Plan*******************
Emergency action is necessary when this student has symptoms such as:
1. _____________________________________________________________
2. _____________________________________________________________
3. _____________________________________________________________
4. _____________________________________________________________
Steps to take during an asthma episode:
1. Give emergency medication:
A. Bronchodilator (quick relief medication)
Medication: ___________________________
Dosage: ______________________________
Can be repeated for severe breathing difficulty _______ times ______minutes apart.
 Call 911 or EMS if minimal or no improvement
2. Seek emergency medical care if this student experiences any of the following:
 If no improvement 15-20 minutes after initial treatment with medication and family
cannot be reached.
 Student exhibits:
o Chest and neck pulled in with breathing
o Hunched over while breathing
o Struggling to breathe
o Trouble walking or talking
o Lips or fingernails turn gray or blue
Special Instructions: _______________________________________________________
_____________________________________________________________________________
________________________________________________________________________
Physician’s Signature:____________________________ Date ___________