Asthma Update Form

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Asthma Update Form

Please take a few minutes to answer the questions below.
Your answers will be used to create an individualized school healthcare plan for your child.
Also, information reported will be shared on a need to know basis with school personnel for health, safety and educational purposes.

Email *

Student's Legal Name (last, first) *

Student Date of Birth *

YYYY

Student Graduation Year *

Type of Asthma *

Exercise Induced

Allergy Related

Non-Allergy Related

Other:

Common Triggers *

Exercise

Pollen

Mold

Dust Mites

Animals

Smoke

Food

Cold/Flu/Illness

Weather

Air Pollution

Other:

List medications (include medication name, dosage and any additional instructions) *

Where will your student keep their medication? *

On their person at all times.

Only in the nurse's office.

Both on their person and an extra in the nurse's office.

Other:

For your child, has 911 ever been called for an asthma attack that did not improve with medication? *

Yes

Please ask your child's doctor to complete this plan. Return plan to me via email nurse@ep309.org or fax 309-694-8322. Asthma Action Plan

Name of parent/person completing this form. *

Submit

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