ASTHMA INFORMATION FORM
Student’s Name: _______________________________
Grade: ____________
Asthma Triggers: (Check all that apply)
__ Exercise
__ Pollen
__ Strong odors
__ Change in temperature
__ Mold
__ Respiratory Infections
__ Animals
__
Food: _____________
__ Carpet
__ Other: _____________
Describe the symptoms your child experiences (e.g. wheezing, coughing, tightness,
other):_____________________________________________________________
What usually helps if an attack occurs? ___________________________________
Medications child takes at home for asthma:
Medication Name:
Dose:
How Often:
_____________________
___________
_______________
_____________________
___________
_______________
Side Effects of Medications? ____________________________________
Does your child use a peak flow meter? ________ Current Best Peak Flow: _________
Number of times child has visited an ER for an acute asthma attack in the last year _____
Additional information/instructions: __________________________________________
Signature of parent/guardian: _________________________ Date: ________________
*All medications brought to school must be accompanied by a written doctor’s order,
with a signed parental permission note. The medication must be in its original container,
clearly labeled, from your pharmacist. Forms are available from the school nurse, or can
be located on the school website under school life/health forms.
PLEASE COMPLETE THE OTHER SIDE OF THIS FORM
EMERGENCY CARE PLAN: ASTHMA
Student: ________________
Grade: ____ School Year: ________ DOB: _________
Mother/Guardian Phone: (H) ________________
Father/Guardian Phone: (H) ________________
Other Emergency Contact: ___________________
Student’s Doctor: _________________________
Doctor student sees for asthma: __________________
Signs of an asthma attack include:
-Difficulty catching breath/ chest tightness or pain
-Itchy chin or neck/ “neck feels funny”
-Difficulty breathing/ rapid breathing
-chest/neck pulled in with breathing
-lips or nails turn blue or gray
(C) __________________
(C) __________________
Phone: _______________
Phone: _______________
Phone: _______________
-coughing/wheezing
-child appears restless/anxious
-child is hunched over
-stops activity and sits still
Action:
1. Stop activity and assist to an upright sitting position.
2. Call the school nurse or school administration if the nurse is not available
3. The nurse can give an inhaler/nebulizer, or a self-directed student can use his/her
own inhaler.
4. Student may return to class if symptoms are relieved.
IF SYMPTOMS WORSEN:
5. Do not leave student alone
6. Call 911
7. Call parent/guardian
Emergency asthma medications:
Medication ordered: _________________________
Dose: _______________
Special Instructions: __________________________________________________
__ Check here if a spacer is used with a metered dose inhaler
__ Check here if student has demonstrated proper use of the inhaler to the school nurse
and is allowed to self-carry and administer.
Written by: ______________________________________ Date: _______________
Signature of parent/guardian: _______________________Date:_________________
*Parent signature denotes permission to share the above information with staff on a need
to know basis, as well as gives permission to speak to the child’s physician as needed.
FASNY2015