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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 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_________________________________________________________________

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 medicine(s): Name of medicine ______________________________

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 healthcare provider: ______________________  Phone: __________________________

Online Medical Reviewer: Adler, Liora C., MD
Online Medical Reviewer: Bass, Pat F. III, MD, MPH
Last Review Date: 8/1/2016
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