Parent/Guardian Questionnaire for Students with Asthma
Student Name___________________________________School Year_______________
Grade _____________Homeroom Teacher _____________________________________
Dear Parent/Guardian,
You noted on the emergency card that your child has asthma. In order to give the
appropriate care, we request that you complete this form and return it to the school nurse.
This information will be used to develop an emergency action plan for your child that
will be shared with appropriate school staff. If there is any change in this information
during the school year, please notify the school nurse in writing.
Thank you,
School Nurse_____________________________________________________________
1. Briefly describe what triggers your child’s asthma symptoms and presenting symptoms
_______________________________________________________________________
_______________________________________________________________________
2. Does your child require treatment before exercise? _____ Yes _____ No
3. Does exercise trigger asthma symptoms? Circle all that apply
Cough Wheeze Shortness of Breath Chest Tightness
Chest Pain
4. Do certain weather conditions affect your child's asthma?
(List)____________________________________________________________________
5. Do you have an asthma management plan? If yes, please give copy to your school nurse
DAILY MEDICATION / NAME OF RX
DOSAGE
WHEN TO USE
1.___________________________________
2.___________________________________
__________
__________
______________
______________
EMERGENCY ASTHMA MEDICATIONS
DOSAGE
WHEN TO USE
1._____________________________________
2._____________________________________
__________
__________
______________
______________
Name of Physician________________________________________Phone___________
Signature of Parent/Guardian________________________________Date____________