A
A
P
20__ - 20__
STHMA
CTION
LAN F OR PRESCHOOL CHILDREN YEAR
Name
DOB
____________________________________________________
_________________________________
Parent/Guardian
________________________________________________________________________________
Ph (Home)
Ph (Cell)
________________________________________________
_____________________________
Doctor
Ph
M
M
S
E
C
-
ATEGORY
OF SEVERITY
ILD
ODERATE
EVERE
XERCISE
INDUCED ASTHMA
Use Controller Medicines at Home Every Day
GO
MEDICINE/ROUTE
HOW MUCH
HOW OFTEN/WHEN
Child is feeling well
Breathing is good
No cough or wheeze
Sleeps through the night
Can play
CAUTION
Rescue Medicine
MEDICINE/ROUTE
HOW MUCH
HOW OFTEN/WHEN
Child is not feeling well
COUGHING day or night
Give a
Stay with child and keep child
Rescue medicine:
Wheezing–hard or noisy
nebulizer
quiet for 15 minutes
breathing
_____________________
treatment
Vomiting after coughing
Encourage child to drink fluids
Other symptoms
If symptoms not improved, may
Trouble breathing
repeat rescue medicine ONCE
Give ____
Nebulizer
Mask
Trouble eating
puffs of
Call parent to report child had
Cranky and tired
metered
Spacer
Inhaler
breathing problem
dose inhaler
Other Signs
IF STILL HAVING
Change in sleep pattern
TROUBLE,
Not playing as usual
FOLLOW RED ZONE
Reaction to asthma trigger
NOTE: Parent should contact the doctor if child needs rescue med >2 times/wk to see if a medication change is necessary.
STOP
Get Help from a Doctor
MEDICINE/ROUTE
HOW MUCH
HOW OFTEN/WHEN
Child is very sick
Give a
Rescue medicine:
Give rescue medicine NOW
Danger-Get Help!
nebulizer
_____________________
treatment
Watch child closely
Medicine is not helping
Repeat rescue medicine in
Give______
Nebulizer
Mask
Constant cough
15 minutes if still in distress
puffs of
Working hard to breathe
Spacer
Inhaler
metered dose
Trouble walking or talking
inhaler
Child looks very sick
Call parent. If not better, call doctor.
IF IN SEVERE DISTRESS, CALL 911.
Doctor signature:
Date
I hereby release the local School Board and their agents and employees and the child care providers from any liability that may result from my
child taking the prescribed medication. I give permission for my child to receive medications and for health care providers to exchange
information regarding the care of my child. I agree to provide rescue medication to be kept at the child care center in case of emergency.
Parent/Guardian:
Date
—
—
/
—
WHITE
CHILD CARE PROVIDER
YELLOW
PATIENT
PARENT
PINK
DOCTOR
Albemarle Pediatric Asthma Coalition
O
03/08
06/09
RIGINAL
REV