Print
Request Appointment

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: _____________________________________

 

Was this helpful?

Yes No
 

Tell us more.

Check all that apply.
 
 
 
 
 
NEXT ▶

Last question: How confident are you filling out medical forms by yourself?

Not at all A little Somewhat Quite a bit Extremely

Thank You!

 
 Visit Other Fairview Sites 
 
 
(c) 2012 Fairview Health Services. All rights reserved.