Asthma action plan

Reviewed & Accepted as EAF &IHP____________ (School Nurse signature) Asthma Action Plan-(To be filled out by physician prior to parent signature) optional photo Name of Student: _____________________________________ Date of Request: ___________________________
Date of Birth: __________ Grade: _____ Campus: ______ Homeroom Teacher: _______ Student ID _______________

According to the NIH Asthma Management Guidelines, this student’s asthma is
( ) Mild intermittent ( ) Moderate persistent ( ) Mild persistent ( ) Severe persistent

This student’s specific signs and symptoms of an asthma attack include: __________________________________________
1. Name, dose, and frequency of preventive medications: GREEN ZONE – GO ZONE!
____________________________________________________________ 2. This patient has Exercise-Induced Asthma? ( ) YES ( ) NO
If yes, what medication should be given for EIA? Use the indicated treatment 15-20 minutes before exercise as needed:
( ) ALBUTEROL MDI 2 puffs ( ) With Spacer / Chamber
( ) ALBUTEROL 1 vial via nebulizer
( ) XOPENEX MDI 2 puffs ( ) With Spacer / Chamber
( ) XOPENEX 1 vial via nebulizer
YELLOW ZONE – CAUTION
( ) OTHER: ____________________________________________________
1. For asthma exacerbation, what fast-acting medication should be used? Use the indicated treatment every 4-6 hours as needed for 24-48 hours:
( ) ALBUTEROL MDI 2 puffs ( ) With Spacer / Chamber
( ) ALBUTEROL 1 vial via nebulizer
( ) XOPENEX MDI 2 puffs ( ) With Spacer / Chamber
( ) XOPENEX 1 vial via nebulizer
( ) OTHER: ____________________________________________________
RED ZONE – DANGER ZONE!
1. For worsening asthma signs, what fast-acting medication should be used? Use the indicated treatment every 20 min. as needed up to three times:
( ) ALBUTEROL MDI 2 puffs ( ) With Spacer / Chamber
( ) ALBUTEROL 1 vial via nebulizer
( ) XOPENEX MDI 2 puffs ( ) With Spacer / Chamber
( ) XOPENEX 1 vial via nebulizer
( ) OTHER: ____________________________________________________
2. Get immediate medical attention—Call 911 if legal guardian is unavailable.

I certify that the above named student has a reactive airway disease and is capable of carrying and self-administering the
above fast-acting medication(s) after complying with the school district’s regulations. Must also complete self carry form.

Physician’s Printed Name: ________________________ Signature: __________________________ Date: __________
Physician’s Telephone Number: ____________________________ FAX Number: _______________________________
I request the indicated medication(s) be given by a school employee. I understand the School District, Board of Trustees, and
District employees shall not be held responsible for damages or injuries resulting from administration of this medication.
I consent to the release of the medical information contained on this form to school officials who have a legitimate educational
interest in the information, according to MISD Board Policy and the Family Education Rights and Privacy Act. I give
permission for the release of confidential information regarding my child’s specific health problems to third parties, other than
school officials, as required to facilitate medical care and/or treatment of my child.
Parent’s Printed Name: __________________________ Signature: ___________________________ Date: __________
Daytime Phone: _________________________________ Parent’s E-mail: _____________________________________
Reviewed & Accepted as EAF &IHP____________ (School Nurse signature) Asthma Action Plan-(To be filled out by physician prior to parent signature) optional photo Student’s Name: ________________________________________________________________ Medications and Amounts: (A) ______________________________ Admin. Time: __________ (B) ______________________________ Admin. Time: __________ (C) ______________________________ Admin. Time: __________ Signatures & Initials: ____________________________ ________ ______________________________ ________ ____________________________ ________ _____________________________ ________ ____________________________ ________ ______________________________ ________ ____________________________ ________ ______________________________ ________ Medication picked up by parent __________________________________ The following medication was destroyed due to failure to pick up the medication prior to the last day of school or expiration of date medication was discontinued: Amount of medication disposed of: __________________________________________________________________________ RN Signature: ________________________________________ Witness Signature: __________________________________ Date: ______________________________________________ Time: ____________________________________________

Source: http://www.mckinneyisd.net/information/docs/ASTHMA%20ACTION%20PLAN.pdf