Asthma Action Plan
Please complete this asthma action form regarding your child’s asthma so that we may have it on file in the
clinic. Contact the school nurse for any questions.
Student Name: Click here to enter text.
Grade: Click here to enter text.Teacher: Click here to enter text.
Parent Name: Click here to enter text.
Phone: Click here to enter text.
Identify the things that trigger an asthma episode for your child:
☐ Exercise
☐ Strong Odors
☐ Respiratory Infections
☐ Chalk dust/Dust ☐ Animal Dander
☐ Smoke
☐ Pollen
☐ Mold
☐ Change in Temperature
☐ Other______________________________________________________
☐ Food______________________________________________________
Asthma Medications Taken at Home
Please list dosage and time taken:
1. Click here to enter text.
2. Click here to enter text.
3.. Click here to enter text.
Rescue or Emergency Medications to be taken at school
1. Click here to enter text.
2. ______________________________
__________________________
My child checks his/her peak flow readings at home: ☐ Yes ☐ No
Personal Best number Click here to enter text.
Emergency action/medication is required when these symptoms occur
1. Click here to enter text.
2. Click here to enter text.
3. Click here to enter text.
4. Click here to enter text.
5. Click here to enter text.
6. Click here to enter text.
Rev. 8/2010