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Important Information About My Child's Asthma

To: __________________________________________ (name of school) Date:____________

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 medications at school:

Name of Medication: 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 Medication______________­__________________________________________________________

How is it taken? __________________ How much? _____________ How often/when? __________________

Name of Medication______________­__________________________________________________________

How is it taken? __________________ How much? _____________ How often/when? __________________

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 medication(s): Name of medication ________________________________________

How it is taken: __________________ How much: _________________ How often/when _______________

2. ___________________________________________________________________________________________

3. ___________________________________________________________________________________________

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 health care provider: ____________________­­__  Phone: _____________________________________

Online Medical Reviewer: Holloway, Beth, RN, M.Ed.
Online Medical Reviewer: MMI board-certified, academically-affiliated clinician
Last Review Date: 6/13/2014
© 2000-2014 The StayWell Company, LLC. 780 Township Line Road, Yardley, PA 19067. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.