School Asthma Management Plan DATE: _______________________
Student Asthma Action Card
Student’s Name:____________________________________________ Grade:_________ DOB:______
Teacher: ___________________________________________Room:___________
Parent/Guardian Name:__________________________________ Ph (H):________________
Address: _____________________________________________ Ph (W):_______________
Emergency Phone Contact #1:______________________ _______________ ___________
Name Relationship Phone
Emergency Phone Contact #2:______________________ _______________ ___________
Name Relationship Phone
Physician Student Sees for Asthma:_______________________________ Ph:______________
Other Physician:______________________________________________ Ph:______________
Daily Asthma Management Plan
Identify the things which start an asthma episode (check each that applies to the student).
___Exercise ___ Strong odors or fumes ____ Other_____________________
___Respiratory infections ____Chalk dust ___Change in temperature
___ Carpets in the room ___Food ___ Animals ___Pollens ___ Molds
Comments:________________________________________________________________
Control of School Environment
(List any environmental control measures, pre-medications, and/or dietary restrictions that the student needs to prevent an asthma episode.)
_____________________________________________________________________________
_____________________________________________________________________________
Peak Flow Monitoring
Personal Best Peak Flow Number__________________________________________________
Monitoring Times:_________________ ______________________ _________________
Daily Medication Plan
Name Amount When to Use
1.__________________________ __________________ ____________________
2. __________________________ __________________ ____________________
3. __________________________ __________________ _____________________
4. __________________________ __________________ _____________________
Emergency Plan: Emergency action is necessary when the Student has symptoms such as
____________________________________________________________________________________
____________________________________ or has a peak flow reading of ___________________________
Steps to take during an asthma episode:
1. Give medications as listed below.
2. Have student return to classroom if: ___________________________________________________________________________________
3. Contact parent if: ____________________________________________________________________________________
4. Seek emergency medical care if the student has any of the following:
No improvement 15-20 minutes after initial treatment with medication and a relative cannot be reached.
Peak flow of _____________________________________
Hard time breathing:
Chest and neck are pulled in with breathing.
The child is hunched over while breathing.
The child is struggling to breathe.
Trouble walking or talking.
Stops playing and cannot start activity again.
Lips or fingernails turn gray or blue.
IF THE ABOVE HAPPENS, GET EMERGENCY HELP NOW!
Emergency Asthma Medications
Name Amount When to Use
1 .________________________ ________________________ ________________________
2._________________________ ________________________ ________________________
3._________________________ ________________________ ________________________
4._________________________ ________________________ _______________________
Comments/Special Instructions
______________________________________________________________________________
______________________________________________________________________________
For Inhaled Medications (Please initial one of the statements below)
____ I have instructed (name)__________________________________________________ in the proper way to use his/her medications. It is my professional opinion that he/she should be allowed to carry and self-administer any of his/her asthma medications while on school property or at school related events.
____ It is my opinion that _____________________________should NOT carry his/her inhaled medication by him/herself.
Physician Signature _________________________________________ Date _______________
Parent Signature ___________________________________________ Date ________________