ASTHMA / REACTIVE AIRWAY DISEASE
HEALTH PACKET INSTRUCTIONS
Licensed Healthcare Provider Orders/Emergency Care Plans:
For Parents/Guardians:
1. Review or complete personal data section – top of page 1.
a. Make any changes or corrections needed.
b. Be sure to include date of last asthma attack, what triggers an
attack and any daily medications given at home.
2. Check whether or not you will allow your student to carry their own
emergency medications – bottom of page 1.
3. Review emergency care plan on reverse on page 2.
a. Make any additions or corrections needed.
b. If no signs or symptoms are circled or highlighted – circle or
highlight those symptoms that are typical for your student.
4. Sign and date parent/guardian consent – bottom of page 1.
For Licensed Healthcare Provider:
1. Complete each line in the Medication Order section – middle of page 1.
2. Review the emergency care plan – page 2.
a. Make any additions or corrections needed.
3. Sign and date Medication Order section – middle of page 1.
Release of Confidential Medical Records/Information:
For Parents/Guardians:
1. Complete name of Licensed Healthcare Provider.
2. Sign, date and list your relationship to the student – bottom of the page.
Self-Carried Medication Contract:
1.
2.
3.
4.
Read and review the printed contract.
Discuss it with your student.
Sign and date the parent/guardian portion – middle of the page.
Your student and the school nurse will complete the bottom portion of the
form at school.
Asthma History:
1. Complete all highlighted sections of the form.
2. Sign and date the completed form at the bottom of the page.
RETURN ALL SIGNED DOCUMENTS TO THE SCHOOL NURSE.
Updated: 11/11/2011