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I need information about...
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? __________________
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 _______________
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: _____________________________________
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