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I need information about...
To: __________________________________________________ (name of school)
The follow information is about my child ___________________________ (name).
My child has __________________________________________
(diagnosis - for example: asthma, cough-variant asthma, or other)
Please make sure that my child's teachers, coaches, and other school employees know the following about my child's condition:
My child's asthma symptoms may worsen or he or she may have an asthma attack from:
Special request(s) to prevent my child's asthma from worsening:
Early signs that my child's asthma may be worsening are:
My child should take the following medicines at school:
Name of medicine: Example: Pulmicort Flexhaler 180mcg
How is it taken? Example: by inhaler How much? Example: 1 puff How often/when? Example: 9:00 AM
Name of medicine__________________________________________________________________
How is it taken? ________________ How much? _____________ How often/when? ______________
Name of medicine_________________________________________________________________
Before physical activity (such as recess, playing outside, physical education or participating in sports) my child should:
If my child's asthma symptoms worsen or if my child has an asthma attack, his or her teacher or other school personnel should:
1. Help my child use rescue medicine(s): Name of medicine ______________________________
How it is taken?: _______________ How much?: ______________ How often/when? ____________
4. Contact parent/guardian/caregiver if symptoms continue to worsen or if attack continues.
Emergency names and numbers:
Name of parent/guardian/caregiver(s): ___________________ Phone: ______________________
Name of healthcare provider: ______________________ Phone: __________________________
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