School Asthma Action Plan Form - Texas Catholic Conference Education Department - 2016
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1
2SAMPLE ASTHMA ACTION PLAN, p. 1
SCHOOL ASTHMA ACTION PLAN
(Please print legibly)
(To be completed at the beginning of each school year and kept on file with the school nurse or office of the
principal)
Student’s name:
Grade:
DOB:
Teachers’ Name:
School Year:
Parent/Guardian:
Home phone:
Address:
Work phone:
Emergency Contact:
/ Relationship:
Phone Number (s):
Physician student sees for asthma:
Phone:
Other physician:
Phone:
Daily Treatment Plan
Please list any medication taken daily to manage asthma including nebulizer treatments, with specific instructions
Name
Purpose
Dosage
When to use
1.
2.
3.
These medications are prescribe for the time period
until
Medical Equipment
Please list any medical equipment this student will need to treat his/her asthma at school.
(i.e. spacer, nebulizer, oxygen, pulse oximeter etc.)
130
Texas Catholic Conference Education Department, 2016
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