Asthma/Allergy Reaction Treatment Plan
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Email address
*
Your email
Student's Name
Your answer
Student's Date of Birth
Your answer
Student's Grade
Your answer
Physician's Name & Phone #
Your answer
Hospital Preference
Your answer
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 #)
Your answer
Parent/Guardian 1 (Name & WORK Phone #)
Your answer
Parent/Guardian 1 (Name & CELL Phone #)
Your answer
Parent/Guardian 2 (Name & HOME Phone #)
Your answer
Parent/Guardian 2 (Name & WORK Phone #)
Your answer
Parent/Guardian 2 (Name & CELL Phone #)
Your answer
Student Medical Report
Asthma
Hypoglycemia
Diabetes
Bee Sting Allergies
Contact Allergies
Food Allergies
Seizures
Other
Allergies/Other
If allergies is checked, please list all allergies or other option
List All Allergies
Your answer
Allergy Information
Life Threatening (Call 911 Immediately
Moderate
Mild
Signs of a Reaction for this Student Include:
Swelling at site of sting or contact
HIves
Difficulty breathing
Hoarseness
Nausea
Diarrhea
Racing pulse
Swelling beyond area of sting or contact
Itching sensation
Swelling of lips
Hacking cough
Abdominal cramps
Shortness of breath
Passes out
Rash over large area or entire body
Tightness in throat
Swelling of tongue
Tightness in chest
Vomiting
Wheezing
Action Plan
Steps to be Taken
Your answer
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.
Asthma Information
Rate the Severity of his/her Asthma
Not severe
1
2
3
4
5
6
7
8
9
10
Severe
Triggers for Student's Asthma Attacks
Illness
Emotions
Fatigue
Weather
Medications
Chemical Odor
Cigarettes
Exercise
Smoke
Allergies
Other
List Other
Your answer
Actions Taken by Student to Relieve Wheezing During an Asthma Attack
Breathing exercises
Rest/relaxation
Drink liquids
Take medication
Inhaler
Nebulizer
Other
List Other
Your answer
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
When ill
Medication to Take at School
What medication will this student need to take in school? (please list name and when taken)
Your answer
What side effects does this student suffer from this medication?
Your answer
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
Your answer
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:
Your answer
Date of Parent/Legal Guardian' Signature:
MM
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DD
/
YYYY
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