Asthma Health Care Action Plan And Authorization For Medication Form

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ASTHMA HEALTH CARE ACTION PLAN & AUTHORIZATION FOR MEDICATION

SCHOOL DIVISION NAME: _____________________________

TO BE COMPLETED BY PARENT:

Child’s Name ___________________________________Date of Birth _______________ School _________________________ Grade _____

Parent/Caregiver _____________________________ Phone (H) _______________ Phone (W) _______________ Phone (Cell) _____________

Address __________________________________________________________ City _____________________________ Zip ______________

Emergency Contact _________________________________________________Relationship _____________________ Phone ______________

____________________________ Office Phone (___) _______________

Name of Provider (Physician/Nurse Practitioner/Physician's Assistant)

Office Fax

(___) _______________

What triggers your child’s asthma attack? (Check all that apply)

Illness

Cigarette or other smoke

Food_______________________________________________________________

Emotions

Exercise/physical activity

Allergies:

Cat

Dog

Dust

Mold

Pollen

Weather changes

Chemical odors

Other: ___________________________________________________________

Describe the symptoms your child experiences before or during an asthma episode: (Check all that apply)

Cough

Tightness in chest

Rubbing chin/neck

Shortness of breath

Breathing hard/fast

Feeling tired/weak

Wheezing

Runny nose

Other ___________________________________________________________

TO BE COMPLETED BY HEALTH CARE PROVIDER:

The child’s asthma is:

Intermittent

Mild Persistent

Moderate Persistent

Severe Persistent

Exercise-induced

Peak Flow

Treatment

SYMPTOMS

Monitoring

WELL

GREEN

Medication

How Much

When

ZONE

Usual medications control

Relievers/Rescue

asthma

Albuterol (with spacer) or

2 puffs 1 min. apart (or 1 nebulizer

2 puffs or 1 nebulizer treatment

Personal

nebulizer

treatment) every 4-6 hrs. as needed

5-15 min. before physical activity

No cough or wheeze

Best =

Other __________________

1 nebulizer treatment; repeat once after 20 minutes if needed

Able to sleep through the

_____

Controllers

night

Inhaled Corticosteroid______

No rescue meds needed

Advair

No activity restrictions

______

Symbicort

(PE & recess are okay)

Other _________________

Leukotriene Modifier:

Singulair

______

Other __________________

Other

__________________

SICK

YELLOW

Continue daily controller medications

ZONE

Give albuterol 2-6 puffs (1 min between puffs) with spacer or 1 nebulizer treatment, wait 20 min

Needs reliever medications

If no improvement, repeat 2-6 puffs or 1 nebulizer treatment, wait 20 mins. Call Parent and/or

more often

Increased asthma symptoms

Provider.

______

If no improvement , CALL 911

(shortness of breath, cough,

chest pain

Wakes at night due to

If child returns to Green Zone:

______

asthma

Continue to give albuterol 2 puffs every 4 hours for 1 to 2 more days

No physical activity

Physical activity as tolerated i.e. PE & recess at school

Unable to do usual activities

EMERGENCY

RED

Give albuterol 2-6 puffs (with spacer) or 1 nebulizer treatment NOW! May repeat once after

ZONE

20 min.

Reliever medications do not

If there is no improvement, call parent and/or 911.

help

<________

Call 911 immediately if:

Very short of breath

Child is struggling to breathe and there is no improvement in 20 minutes after taking albuterol

Constant cough

Child has trouble talking or walking

Child has lips or fingernails that are gray or blue

Child’s chest or neck is pulling in with breathing

PATIENT/STUDENT INSTRUCTIONS:

Student has been instructed in the proper use of all his/her asthma medications, and in my opinion, the student can carry and use his/her inhaler at school

Student is to notify his/her designated school health officials after using inhaler per school protocol

Student needs supervision or assistance to use his/her inhaler

Student should NOT carry his/her inhaler while at school

________________________________________

____________________________________

________

Valid for current school

HEALTH CARE PROVIDER SIGNATURE

PLEASE PRINT PROVIDER’S NAME

DATE

year

I give permission for school personnel to follow this plan, administer medication and care for my child and contact my provider if necessary. I assume full

responsibility for providing the school with prescribed medication and delivery/monitoring devices. I approve this Asthma Management Plan for my child.

________________________

_____________________________

___________________

PARENT SIGNATURE

DATE

CINCH

Virginia Asthma Coalition

Cc: principal ____ office staff ____ librarian ____cafeteria mgr. ____ bus driver/transportation ____ Coach/PE ____ teachers ___

revision: May, 2010