School Name: __________________________ ASTHMA ACTION PLAN
Student Name________________________________ Date of Birth ____________School___________________________ Student ID Number________________________ Grade ____Medication Allergies__________________________________ Activities student participates in at school: _________________________________________________________________
Asthma symptoms are triggered by:
Exercise Illness Pollen Smoke Dust Air Pollution Animals Cold Air Molds Foods (list)
Please list any other triggers: ___________________________________________________________________________
Usual Asthma Symptoms: Cough Shortness of Breath Chest Tightness Wheeze Other___________
If a student has any of the following symptoms: chest tightness, difficulty Call 911 for any of these! breathing, wheezing, excessive coughing, shortness of breath 1.Stop activity & help student to a sitting position If breathing does not improve after medication is given 2. Stay calm, reassure student Student is having trouble walking or talking 3. Assist student with the use of their inhaler Student is struggling to breathe 4. Escort student to the health room or call for health room staff for Student’s chest and/or neck is pulling in while breathing immediate assistance. Never send the student to the health room alone! Student’s lips are blue, and/or INHALER IS KEPT: __________________________ Student must hunch over to breathe HEALTH CARE PROVIDER,Please complete all items in box: ICD 9 Code: 493.9 or ________ Asthma Severity: Intermittent Mild persistent Moderate persistent Severe persistent Controller Medication given at home: __________________________________________________________________________________________________ Name
__________________________________________________________________________________________________ Name
Quick Relief Medication:
Albuterol ____puffs every ___ min. and as needed up to ___ puffs per hour. May repeat every___hrs
Albuterol 10-15 min before exercise Routinely As Needed. Activity limitations: ________________
OR, Albuterol or (___________________) solution as needed, _____ mg by nebulizer every ____ to ____hours Asthma Symptoms Asthma Symptoms Asthma Symptoms Take Quick Relief Medication Now! Take Quick Relief Medication Now!
Use quick relief inhaler before exercise
Call 911 & continue to give Quick Relief Medication every 20 minutes until EMS arrives!
Parent/guardian-call medical provider if
Student can self carry medication? Yes □ No □. Student can self-administer medication? Yes □ No □ Provider signature_____________________________Date ___________Provider printed name______________________________ Provider phone___________________________Provider fax________________________Provider email______________________
Parent/Guardian signature_______________________________________________Date______________________________________ Home phone__________________________ Cell phone ______________________Work phone ________________________________ School Nurse signature ________________________________Date_____________Phone_____________________________________
Assess the effectiveness of the IHP and AAP
El Congreso de la República, de conformidad con el Artículo 104 de la Constitución Política del Perú, mediante la Ley Nº 29157 ha delegado en el Poder Ejecutivo la facultad de legislar sobre materias específicas con la finalidad de facilitar la implementación del Acuerdo de Promoción Comercial Perú-Estados Unidos y su protocolo de enmienda así como el apoyo a la competitividad económi
Port Royal Oral Surgery, P.A. ANSWER ALL QUESTIONS by circling Yes (Y) or No (N) All responses are kept confidential! G. Insulin or Oral Anti-Diabetic drugs? . Y N H. Digitalis, Inderal, Nitroglycerin or other heart drugs. Y N Are you taking or have you ever taken Bisphosphonate for osteoporosis, multiple myeloma or 4. Are you now under a physician’s care for other can
School Name: __________________________ ASTHMA ACTION PLAN