Asthma/Allergy Reaction Treatment Plan
Student's Date of Birth
Physician's Name & Phone #
Parent/Legal Guardian's Daytime Phone Numbers:
Please enter Parent(s) or legal Guardian(s) contact name & phone numbers that may apply
Parent/Guardian 1 (Name & HOME Phone #)
Parent/Guardian 1 (Name & WORK Phone #)
Parent/Guardian 1 (Name & CELL Phone #)
Parent/Guardian 2 (Name & HOME Phone #)
Parent/Guardian 2 (Name & WORK Phone #)
Parent/Guardian 2 (Name & CELL Phone #)
Student Medical Report
Bee Sting Allergies
If allergies is checked, please list all allergies or other option
List All Allergies
Life Threatening (Call 911 Immediately
Signs of a Reaction for this Student Include:
Swelling at site of sting or contact
Swelling beyond area of sting or contact
Swelling of lips
Shortness of breath
Rash over large area or entire body
Tightness in throat
Swelling of tongue
Tightness in chest
Steps to be Taken
All medications to be used in the Action Plan are to be provided by Parent/Guardian with the appropriate Authorization for Administration of Medication Form completed and signed.
Rate the Severity of his/her Asthma
Triggers for Student's Asthma Attacks
Actions Taken by Student to Relieve Wheezing During an Asthma Attack
Asthma Medications Student Takes and How Often
Every day (preventative medication)
For wheezing/coughing (emergency medication)
Just before exercise
Only certain times of the year
Medication to Take at School
What medication will this student need to take in school? (please list name and when taken)
What side effects does this student suffer from this medication?
Action Plan - Please List Steps to be Taken Below
All medications to be used in the Action Plan are to be provided by Parent/Guardian with the appropriate Authorization for Administration of Medication form completed and signed
PLEASE NOTE--911 will be called if...
- An Epi Pen or Epi Pen Jr. is used.
- Signs or symptoms of a reaction persists or worsens even after the ACTION PLAN steps have been taken.
- The school personnel believe the student is in immediate danger.
PARENT SIGNATURE - Please read before signing
I certify that the information given above is complete and accurate. I acknowlede that I have a continuing obligation to infrom the school of any changes in this student's health status that are relevant to the information requested by this form. I understand and agree that the above information may be shared with school staff. I understand that if my child receives medications at school, the signed Authorization for Administration of Medication needs to be completed and signed. This authorization shall continue until the last day of this school year, or util I notify the school (in writing), that I revoke the authorization.
Parent/Legal Guardian's Signature:
Date of Parent/Legal Guardian' Signature:
Send me a copy of my responses.
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This form was created inside of Concordia Lutheran Church and School.