Looking for a Child Care Forms And Templates? Download it for free!

Maryland State Child Care/Nursery School

Triggers (list)

Asthma Medication Administration Authorization Form

for ___/___/__ to ___/___/___

ASTHMA ACTION PLAN

(not to exceed 12 months)

Student’s

Name:__________________________________ DOB:________________ PEAK FLOW PERSONAL BEST:__________________

□

ASTHMA SEVERITY:

Exercise Induced

Intermittent

Mild Persistent

Moderate Persistent

Severe Persistent

GREEN ZONE : Long Term Control Medication — use daily at home unless otherwise indicated

 Breathing is good

Medication

Dose

Route

Frequency

 No cough or wheeze

 Can work, exercise, play

 Other: __________________________

 Peak flow greater than _______

(80% personal best)

(Rescue Medication)



Prior to exercise/sports/ physical education

If using more than twice per week for exercise, notify the health care provider and parent/guardian.

YELLOW ZONE: Quick Relief Medications — to be added to Green zone medications for symptoms

 Cough or cold symptoms

Medication

Dose

Route

Frequency

 Wheezing

 Tight chest or shortness of breath

 Cough at night

 Other: ___________________________

 Peak flow between _____ and _____

If symptoms do not improve in ______ minutes, notify the health care provider and parent/guardian.

(50%‐79% personal best)

If using more than twice per week, notify the health care provider and parent/guardian.

RED ZONE: Emergency Medications— Take these medications and call 911

 Medication is not helping within 15‐20 mins

Medication

Dose

Route

Frequency

 Breathing is hard and fast

 Nasal flaring or skin retracts between ribs

 Lips or fingernails blue

 Trouble walking or talking

 Other:_________________________

Contact the parent/guardian after calling 911.

 Peak flow less than __________

50% personal best)

(

Health Care Provider and Parent Authorization

I authorize the child care provider to administer the above medications as indicated. Student may self‐carry medications: [School‐age children) Yes No

Prescriber signature: _________________________________ Date: _________ Parent / Guardian Signature: _________________________ Date: ___________

By signing below, I certify that the child is authorized to self‐carry/self‐administer medication and authorize the child to self‐carry/self‐administer the

medications indicated during any child care and before/after school programs.

Prescriber signature: _________________________________ Date: _________ Parent / Guardian Signature: _________________________ Date: ___________

Reviewed by Child Care Provider: Name: _____________________________________ Signature: __________________________________ Date: ___________

6/18/2013