Form Ci 7 - Asthma Action Plan - Medication Authorization Form
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1aSThMa acTion Plan/
MedicaTion auThoriZaTion ForM
Student Name: ______________________________________________________________________
Student ID#: _________________________________
School/Year: ____________________________________20 ______ to 20 ______ Grade: ___________ Teacher: _____________________________________
Parent/Guardian: _____________________________________________________
Contact Number: _____________________________________________
Physician’s Name: ____________________________________________________
Physician’s Phone/Fax: ________________________________________
Important InstructIons
1. NO SMOKING in your home or car, even if your child is not with you.
2. Always use a spacer with inhalers (MDIs).
3. Shake inhaler before every spray (puff ).
4. Remove, control and stay away from known triggers in your child’s environment.
5. Clean plastic part of inhaler weekly using package directions.
6. Prime inhaler after opening and before use if not used in more than two weeks. Proair-three puffs, all others four puffs.
CHILD’S TRIGGERS ARE: (circle or check all that apply to your child)
❏ Respiratory infections or flu
❏ Mold
❏ Pollen
❏ Dust, dust mites
❏ Weather/temperature changes
❏ Indoor pets
❏ Exercise
❏ Strong odors or sprays
❏ Indoor/outdoor pollution
❏ Household cleaners
❏ Strong emotion
❏ Cockroaches
❏ Smoke
Other allergies ___________________________________________________________________
green Zone - all clear
uSe conTroller MedicineS
aSThMa iS Well conTrolled
no controller medicine needed at this time.
Medicine
Method
How much How often
You should have:
______________________ _____________ __________ ________times per day
No wheezing
No coughing
______________________ _____________ __________ ________times per day
No chest tightness
______________________ _____________ __________ ___________________
No waking up at night because of asthma
______________________ _____________ __________ ___________________
No problems with play because of asthma
15 minutes before exercise use _______ puffs (inhaled) ________________________
*Rinse child’s mouth after using inhaled steroids (daily/controller medicines).
Peak flow number from _______to ________
yelloW Zone - cauTion! - Take acTion
uSe conTroller MedicineS
aSThMa geTTing WorSe
continue to use green zone daily medicines and add:
You may have:
Medicine
Method
How much
How often
Albuterol/Xopenex
inhaled
____ puffs OR ____ vial
Every____hours prn
Wheezing
Coughing
_____May repeat after 20 minutes x 1 (Indicate with check)
Chest Tightness
Also take:
First signs of a cold
______________________ _____________ __________ ___________________
Coughing at night
If yellow-zone symptoms continue for 24 hours or child needs extra rescue medicine more
than twice per week, call your child’s doctor.
Peak flow number from _______to ________
red Zone - SToP! geT helP noW!
Take Quick relieF Medicine
You may have:
ThiS iS an eMergency!
Quick relief medicine that is not helping
Continue to use green zone medicines and do the following:
Wheezing that is worse
Use_______ puffs OR 1 vial Albuterol/Xopenex inhaled every 20 minutes
Faster breathing
for a total of _______ doses.
Blue lips or nail beds
Trouble walking or talking
CALL DOCTOR NOW! If you cannot reach doctor, call 911 or go directly to the
Chest and neck pulled in with each breath
emergency room. Do not wait!
Or peak flow less than _________
Physician Signature: _________________________________________________________________________
Date: ________________________________
Parent/Guardian Signature: ___________________________________________________________________
Date: ________________________________
School Health Nurse Signature: ________________________________________________________________
Date: ________________________________
(SCHOOL NURSE USE ONLY) Student carries inhaler: Y / N Inhaler in the Health Room: Y / N Inhaler in classroom: Y / N
Form # CI 7 | 6/09
Please complete form and return to your student’s school.
7
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