Camp Emergency Medical Plan

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CAMP EMERGENCY MEDICATION PLAN
Scout'sName:______________________________________ Date of Birth: _____________ Pack or Troop #:________
Camp Hinds
Camp Telephone & Fax: 207-655-4878
TO BE COMPLETED BY PARENT OR GUARDIAN:
I authorize the exchange of medical information about my child’s asthma between the physician’s office and camp nurse.
Parent or Guardian signature: _____________________________________________
Date:__________
Parent or Guardian tel.# home: ____________________
work:_____________________ cell phone:____________________
Physician/Healthcare Provider Name:
Parent concerns:
My child may carry and use his/her:
inhaled asthma medicine
Yes
No
Epi-Pen
Yes
No
N/A
TO BE COMPLETED BY CAMPER’S PHYSICIAN/HEALTHCARE PROVIDER
:
Provider name:
____________________________
Tel.#: __________________ Fax# __________________
NO changes from previous plan
Peak Flow:
:
________
Child’s predicted, or personal best peak flow
Date:
Child's Green Zone: ______________
Yellow Zone: _______________
Red Zone: below _______
Medications:
Preventive (Controller) Medications:
______________________________________________________________
______________________________________________________________________________________________
Quick Relief Medications:
(check the appropriate quick relief med, circle device, list dose/ frequency):
Albuterol (Proventil, Ventolin)
Pirbuterol (Maxair)
Other:_____________________________
4Inhaler with spacer OR nebulizer
4 Dose/Frequency: ______________________________________________
Allergies /Triggers for asthma:
None known
Avoid animals
Other triggers to avoid: ____________________________________________________________________________
Exercise Pretreatment Instructions
(check all that apply)
Give 2 puffs of quick relief inhaler 15 minutes prior to recess/ physical education and/ or __________________________
May repeat 2 puffs of quick relief inhaler if symptoms recur with exercise, or ____________________________________
Measure Peak Flow prior to recess / physical education; restrict aerobic activity when child’s peak flow is below ________
Asthma Exacerbation Treatment Instructions:
YELLOW ZONE: If child is coughing, wheezing or short of breath, and/or peak flow is in Yellow Zone:
Give 2 puffs of child’s quick relief inhaler with spacer (or nebulizer treatment). May be repeated in 10 minutes if doesn’t
recover to Green Zone. Notify parents of exacerbation.
Other: _____________________________________________________________________________________
RED ZONE: If child is in respiratory distress, and/or peak flow is in Red Zone:
Give 4 puffs quick relief inhaler (or nebulizer treatment), and call parent and Healthcare Provider.
Call 911 if child does not improve quickly or parents/Healthcare Provider cannot be reached.
Other: _____________________________________________________________________________________
Special Instructions:
Maine law now permits campers to carry and use inhaled medications and Epi-pen after demonstrating appropriate use of
Inhalers and or Epi-Pen to camp nurse. Please check appropriate boxes below:
:
Inhaled medication
Epi-pen
This camper has the knowledge and skill to carry and use
:
Inhaled medication
Epi-pen
This camper is not able to carry and use by himself/herself
Please contact Healthcare Provider and parent if camper is using quick relief medicines more than 2 times a week
(i.e. in excess
of pre-exercise treatment)
Other: ____________________________________________________________________________________________
__
_________
________________________________________
Healthcare Provider signature
Date
TO BE COMPLETED BY CAMP NURSE:
This camper demonstrates knowledge and skill to carry and use:
Inhaler medications
YES
NO
________________________________
___________
Epi-Pen
YES
NO
N/A
Camp Nurse Signature
Date
57
( revised for camp use 1/1/2007)

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