Asthma Action Plan Sheet - 2007 printable pdf download

North St. Paul

School District 622

Maplewood

Oakdale

ASTHMA ACTION PLAN

Student Name: ___________________________________________________ Wt: ________ DOB: ___________

Parent/Guardian: ________________________________________________________________________________

Home Ph: ____________________________________ Cell or Work Ph: ___________________________________

Address: _______________________________________________________________________________________

Parent/Guardian: ________________________________________________________________________________

Home Ph: ____________________________________ Cell or Work Ph: ___________________________________

Address: _______________________________________________________________________________________

Emergency Contact: _______________________________ Relationship: ______________ Ph: ________________

Asthma Care Provider: _______________________________________________________ Ph: ________________

Asthma Care Clinic: _________________________________________________________ Fax: ________________

Other Physician: ____________________________________________________________ Ph: ________________

Daily Asthma Management Plan

Identify the things which start an asthma episode (check all that apply):

___ Animals

_____ Pollens

_____ Food: ________________

___ Change in temperature

_____ Strong odors/fumes

_____________________

___ Exercise

_____ Respiratory infections

_____ Other: ________________

___ Molds

_____________________

Control of School Environment: (List any environmental control measures, pre-medications, and/or dietary restrictions

that the student needs to prevent an asthma episode.)

______________________________________________________________________________________________

Peak Flow Monitoring:

Personal best: ___________________________________________________________________________________

Monitoring times: ________________________________________________________________________________

(Turn Over for Backside…)

Asthma Action Plan Sheet - 2007