Asthma Medication Administration Form - Office Of School Health
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1
2ASTHMA MEDICATION ADMINISTRATION FORM
PROVIDER MEDICATION ORDER FORM—Office of School Health—School Year ______–______
Student Last Name
First Name
Middle Initial
Male
Date of Birth __ __ / __ __ / __ __ __ __
Female
M M
D D
Y Y Y Y
OSIS # __ __ __ __ __ __ __ __ __
School Name, Number, Address, and Borough:
Attach Student Photo
To This Sheet
DOE District __ __
Grade ______
The Following Section Completed By Student’s HEALTH CARE PRACTITIONERS
Diagnosis
Control
Severity
(
)
see NAEPP Guidelines
(see NAEPP Guidelines)
Asthma
Well Controlled
Intermittent
Not Controlled
Mild Persistent
Unknown
Moderate Persistent
Severe Persistent
Student Asthma Risk Assessment Questionnaire (Y = Yes, N = No, U = Unknown)
History of near-death asthma requiring mechanical ventilation
Y
N
U
History of life-threatening asthma (
)
Y
N
U
loss of consciousness or hypoxic seizure
History of asthma-related PICU admissions (ever)
Y
N
U
Received oral steroids within past 12 months
Y
N
U ____ times last : __ __ /__ __ /__ __
History of asthma-related ER visits within past 12 months
Y
N
U ____ times
History of asthma-related hospitalizations within past 12 months
Y
N
U ____ times
History of food allergy or eczema, specify: _________________
Y
N
U
Quick Relief In-School Medication (Select ONE)
In-School Instructions
Standard Order:
2 puffs/1 AMP
Give
q 4 hrs. PRN for coughing,
Albuterol MDI
®
[Ventolin
MDI can be provided by school
wheezing, tight chest, difficulty breathing or shortness of breath (“asthma flare
symptoms”). Monitor for 20 mins or until symptom-free. If not symptom-free within
for shared usage (plus individual spacer)]:
[Parent must sign back]
20 mins may repeat ONCE.
If in Respiratory Distress*:
6 puffs/1AMP
Call 911 and give
; may
MDI w/ spacer
repeat q 20 minutes until EMS arrives.
DPI
Pre-exercise:
2 puffs/1 AMP 15-20 mins before exercise.
URI Symptoms or Recent Asthma Flare (within 5 days):
.
Other: Name: ________________ Strength: ______
2 puffs/1 AMP @ noon for 5 days.
.
Dose: _____ Route: ______ Time Interval: q ___
Special Instructions:
hrs
Controller Medications for In-School Administration
Standing Daily Dose:
(Recommended for Persistent Asthma, per NAEPP Guidelines)
___ puffs/1AMP ONCE a day at ___ AM or ___ PM
Fluticasone MDI
®
[Flovent
110 mcg MDI can be provide
Special Instructions:
[Parent must sign back]
by school for shared usage]:
MDI w/ spacer
DPI
Other: Name: ________________ Strength: ______
Dose: _____ Route: ______ Time Interval: q ___ hrs
Select the most appropriate option for this student:
Home Medications (
)
include over the counter
Nurse-Dependent Student: nurse must administer medication
Supervised Student: student self-administers under adult supervision
Reliever _______________________
Independent Student: student is self-carry / self-administer (**
)
Parent Initials Back
Controller ______________________
Other _________________________
________ I attest student demonstrated the ability to self-administer the prescribed
Practitioner
medication effectively for school / field trips / school sponsored events.
Initials
Health Care Practitioner Last Name
First Name
Signature
(Please Print)
Date __ __ /__ __ /__ __ __ __
Address
Tel. ( _ _ _ ) _ _ _ - _ _ _ _ Fax ( _ _ _ ) _ _ _ - _ _ _ _
NPI # _ _ _ _ _ _ _ _ _ _
CDC and AAP strongly recommend
Email Address
NYS License # (Required)
annual influenza vaccination for all
children diagnosed with asthma.
Turn to PAGE 2
INCOMPLETE PRACTITIONER INFORMATION WILL DELAY IMPLEMENTATION OF MEDICATION ORDERS. REV 4/17
FAX COMPLETED FORMS TO 347-396-8945
.
FORMS CANNOT BE COMPLETED BY A RESIDENT
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