Fillable Asthma Action Plan Ages 0 - 11 Years printable pdf download

This form is not in compliance with CT DPH Daycare Licensing regulation 19a-79-9a, and Section 19a-79-9a

Administration of Medications, Order From an Authorized Prescriber/Parent's Permission

Asthma Action Plan

STATE OF CONNECTICUT

Ages 0 – 11 Years

DEPARTMENT OF PUBLIC HEALTH

Name:

Birth Date:

Date:

Parent/Guardian Phone #’s:

Provider Phone #:

Fax #:

(or stamp)

Important! Things that make your asthma worse (Triggers): ☒ smoke

☐ pets

☐ mold

☐ dust

☐ tree/grass/weed pollen ☐ colds/viruses

☐ exercise

☐ seasons:

other:

Severity Classification: ☐ Severe Persistent ☐ Moderate Persistent ☐ Mild Persistent ☐ Intermittent

GO – You’re Doing Well!

SE THESE MEDICINES EVERY DAY TO PREVENT SYMPTOMS

CONTROLLER MEDICINE

DIRECTIONS

You have all of these:

 Breathing is good

___________________________________

______________________________________

 No cough or wheeze

 Sleep through

the night

___________________________________

______________________________________

 Can work

☐ If your child usually has symptoms with exercise then give:

and play

___________________________________

______________________________________

Peak Flow may be useful

 Inhalers work better with spacers. Always use with a mask when prescribed.

for some kids.

CAUTION – Slow Down!

Continue with Green Zone Medicine and Add:

You have any of these:

RESCUE MEDICINE

DIRECTIONS

 First signs of a cold

 Exposure to known trigger

_____________________________________ ______________________________________

 Cough

Then: Wait 20 minutes and see if the treatment(s) helped

 Wheeze



If you are GETTING WORSE or NOT IMPROVING after the treatment(s) GO TO RED ZONE

 Tight chest



If you are BETTER, continue treatments every 4 to 6 hours as needed for 24 to 48 hours

 Coughing at night

Then:

If you still have symptoms after 24 hours, CALL YOUR DOCTOR and if he/she agrees:



Start: ________________________________________________________________

If rescue medication is needed more than 2 times a week, call your doctor at: _______________________

DANGER – Get Help!

SEEK MEDICAL HELP NOW!

AKE THESE MEDICINES AND

RESCUE MEDICINE

DIRECTIONS

Your asthma is

getting worse fast:

 Medicine is not helping

______________________________________ _______________________________________

 Breathing is hard and fast

Then:

Wait 15 minutes and see if treatment helped

 Nose opens wide



If GETTING WORSE or NOT IMPROVING, go to the hospital or call 911

 Can’t talk well



If you are getting BETTER, continue treatments every 4 to 6 hours and call your doctor – say you are



Getting nervous

having an asthma attack and need to be seen TODAY!

Then:

If your doctor agrees, start: _________________________________________________



Make an appointment with your primary care provider within two days of an emergency visit, hospitalization, or anytime for ANY problem or question with asthma

School Nurse:

Call provider for control concerns or if rescue medication is used more than 2 times/week for asthma symptoms

Parents:

Call your doctor for control concerns or if rescue medication is used more than 2 times/week for asthma symptoms

___________________

REQUIRED

EALTHCARE

ROVIDER

CHOOL

EDICATION

UTHORIZATION

FOR

as stated in accordance with CT State Law and Regulations 10-212a



Self–Administration:

This student is capable to safely and properly self-administer this medication OR

This student is not approved to self-administer this medication

Signature:_________________________________Provider Printed Name:___________________________Date:_____________ For use from ______ to ______

Parent/Guardian Consent:

REQUIRED

 I authorize this medication to be administered by school personnel OR  I authorize the student to possess and self-administer medication.

I also authorize communication between the prescribing health care provider, the school nurse, the school medical advisor and school-based clinic providers necessary for

asthma management and administration of this medication.

* Bring asthma meds and spacer to all visits

Parent/Guardian Signature: ____________________________________ Date: _____________