Child Care Asthma Action/management Plan Template
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1
2CHILD CARE ASTHMA/ALLERGY
ACTION CARD
ID
DAILY ASTHMA/ALLERGY MANAGEMENT PLAN
Name: ____________________________________ ____________________________
Photo
Grade: _____________________________ DOB:______________________________ •
Identify the things that start an asthma/allergy episode
Parent/Guardian Name: ___________________________________________________
(Check each that applies to the child)
Address:_______________________________________________________________
— Animals
— Bee/Insect Sting
— Chalk Dust
— Change in Temperature
Phone (H): __________________________ (W): ______________________________
— Dust Mites — Exercise
— Latex
— Molds
Parent/Guardian Name: __________________________________________________
— Pollens
— Respiratory Infections — Smoke
— Strong Odors
Address: _______________________________________________________________
— Food: ______________________________________________________________
Phone (H): __________________________ (W): ______________________________
— Other: ______________________________________________________________
Other Contact Information: ________________________________________________
Comments: ____________________________________________________________
Emergency Phone Contact #1 ______________________________________________
______________________________________________________________________
Name
___________________________________ __________________________________ •
Peak Flow Monitoring (for children over 4 years old)
Relationship
Phone
Emergency Phone Contact #2 _____________________________________________
Personal Best Peak Flow reading: __________________________________________
Name
___________________________________ __________________________________
Monitoring Times: __________________ _________________ _________________
Relationship
Phone
•
Physician Child Sees for Asthma/Allergies: ___________________________________
Control of Child Care Environment (List any environmental control measures, pre-
Phone: ________________________________________________________________
medications, and/or dietary restrictions that the child needs to prevent an asthma/allergy
Other Physician: ________________________________________________________
episode.) ______________________________________________________________
Phone: ________________________________________________________________
______________________________________________________________________
•
Daily Medication Plan for Asthma/Allergy
Name
Amount
When to Use
1
2
3
4
OUTSIDE ACTIVITY AND FIELD TRIPS
The following medications must accompany child when participating in outside activity and field trips:
Name
Amount
When to Use
1
2
3
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