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Education and
Program
ID Photo

Name Relationship Phone
i Name Relationship Phone
Physician Treating Student for Asthma" 	 	 Ph:
Other Physician: ' Ph;

f EMERGENCY PLAN ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^f
F.merpency action is necessary when the student has symptoms such as, , >
: , or has a peak flow reading of
• Steps to take during an asthma episode:
 1 1. Check peak flow.
 ; 2. Give medications as listed below. Student should respond to treatment in 15-20 minutes.
 '• 3. Contact parent/guardian if		
  4. Re-check peak flow.
  5. Seek emergency medical care if the student has any of the following:
       • Coughs constantly
       • No improvement  15-20 minutes after initial treatment
         with medication and a relative cannot be reached.,

       • Peak flow of               	
       • Hard time breathing with:
         • Chest and neck pulled in with breathing
         • Stooped body posture
         • Struggling or gasping
       • Trouble walking or talking
       • Stops playing and can't start activity again
       • Lips or fingernails are grey or blue

 Emergency Asthma Medications
                  Name
               IF THIS HAPPENS, GET
              EMERGENCY HEIP Now!
Amount
                                When to Use
1.
                                       See reverse for more instructions

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DAILY ASTHMA MANAGEMENT PLAN
• Identify the things which start an asthma episode (Check each that applies to the student.)
D Exercise                               Q   Strong odors or fumes      D  Other	
D Respiratory infections                    D   Chalk dust / dust	
D Change in temperature                    D   Carpets in the room
D Animals                              d   Pollens
D Food	           d   Molds
Comments	—	——	——	—
• Control of School Environment
 (List any environmental control measures, pre-medications, and/or dietary restrictions that the student needs to prevent an asthma
 episode.)	   _	
» Peak Flow Monitoring
 Personal Best Peak Flow number:
 Monitoring Times:  	
• Daily Medication Plan
                  Name                               Amount                         When to Use
1. _	.	
2.	:	:	—
3.	
4. ___	_____	
COMMENTS / SPECIAL INSTRUCTIONS
FOR INHALED MEDICATIONS
   ID I have instructed	in the proper way to use his/her medications. It is my
      professional opinion that	should be allowed to carry and use that medication by
      him/herself.
   D It is my professional opinion that	should not carry his/her inhaled medication by him/herself.
                           Physician Signature                                       Date
                           Parent/Guardian Signature                                  Date
    AAFA • 1233 20th Street, N.W., Suite 402 , Washington, DC 20036 • www.aafa.org • 1-800-7-ASTHMA
                                                                                                     02/00

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