Name: ______________________________________Grade:______________Age:______________

Teacher:____________________Homeroom/Section: ____________________

Parent/Guardian Name:______________________________Phone:(H)_____________

Address: _________________________________________Phone:(W)_____________

Parent/Guardian Name:______________________________Phone:(H)_____________

Address: _________________________________________Phone:(W)_____________

Emergency Phone Contact #1:

Name________________________Relationship________________Phone_____________

Emergency Phone Contact #2:

Name________________________Relationship________________Phone_____________

Physician Student sees for Asthma:_________________________________Phone:______________

Other Physician: ____________________________Phone: ________________

DAILY ASTHMA MANAGEMENT PLAN:

•Identify the things which start an asthma episode (check each that applies to student)

_____Exercise _____Strong odors or fumes

_____Respiratory infections _____Chalk dust

_____Change in temperature _____Carpets in the room ______ Molds

_____Animals Pollens Food

Comments: _____________________________________________________________________

•Peak Flow Monitoring ______Yes ______ No Personal Best Number:___________________

Zones:Green _______Yellow ______ Red ______

•Daily Medication Plan

Name Amount When to Use

1. ___________________ _________________ ________________________

2. ___________________ _________________ ________________________

3. ___________________ _________________ ________________________

•Emergency Asthma Medications

Name Amount When to Use

1.___________________ _________________ ________________________

2. ___________________ _________________ ________________________

3. ___________________ _________________ ________________________

COMMENTS/SPECIAL INSTRUCTIONS:___________________________________________ ______________________________________________________________________________

FOR INHALED MEDICATIONS: (Please complete for inhalers that need to be brought to school)

_______I have instructed ___________________________in the proper way to use his/her medications. It is my professional opinion that he/she should be allowed to carry and use that medication by him/herself.

_______It is my professional opinion that _________________________should not be allowed to carry his/her inhaled medication by him/herself.

______________________________________ ______________

Physician Signature Date

______________________________________ ______________

Parent Signature Date

(3/00)