Form Dhmh-4758 - Maryland Medication Administration Authorization Form Page 2
ADVERTISEMENT
1
2ASTHMA, ALLERGY AND/OR SEIZURE ACTION PLAN
Must complete along with Medication Authorization Form
Please indicate in the box below the desired action plan for children in cases of asthma, allergies and/or seizures:
Is the child asthmatic? ☐YES
☐NO
Asthma Severity: ☐Exercise Induced ☐Intermittent ☐Mild Persistent ☐Moderate Persistent ☐Severe Persistent
Desired Treatment:
Epinephrine:
Antihistamine:
Other:
Call 911:
________________________________________________________________
_______________
Parent/Guardian’s Signature
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal