OCR Document
TO BE COMPLETED BY PARENT/GUARDIAN:
Student’s Name Date of Birth School Grade
Parent/Guardian Phone (H) Phone (W) Phone (Cell)
Parent/Guardian Phone (H) Phone (W) Phone (Cell)
Emergency Contact Relationship Phone
Name of Physician Office Phone Number
What triggers your student's asthma attack? (Check all that apply)
|Illness |Cigarette or other smoke |Food _________________________ |Other |
|Emotions |Exercise |Weather changes |
|allergies |Cat |Dog |Dust |Mold |pollen |
Describe the symptoms your student experiences before or during an asthma episode: (Check all that apply)
( Cough ( “Tightness" in the chest ( Rubbing chin/neck
( Shortness of breath ( Breathing hard/fast ( Feeling tired/weak
( Wheezing ( Runny nose ( Other
|TO BE COMPLETED BY PHYSICIAN: |
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|The student’s asthma is: ( mild persistent ( moderate persistent ( severe persistent ( exercised induced |
|Peak Flow |
|Symptoms OR Monitoring |
|Treatment |
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|WELL |
|No cough or wheeze |
|Able to sleep through the night |
|Able to run and play |
|Usual medications control asthma |
|GREEN ZONE |
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|> ____________ |
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|Relievers |
|How Much |
|When |
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|( Xopenex MDI |
|( With spacer |
|2 puffs 1 minute apart |
|every 4 hours pm |
|( 20 min before exercise |
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|( Albuterol, Proventil, or Ventolin MDI |
|( With spacer |
|2 puffs 1 minute apart |
|every 4 hours pm |
|( 20 min before exercise |
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|( Nebulizer treatment: |
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|Controller meds taken at home: |
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|SICK |
|Increased asthma symptoms (shortness of breath, cough. chest pain) |
|Wakes at night due to asthma |
|Unable to do usual activities |
|Needs reliever medications more often |
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|YELLOW ZONE |
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|______ to ______ |
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|Give Albuterol/Xopenex as ordered. |
|( If symptoms worsens move to red zone. |
|( If no improvement after 20 minutes, repeat 2 puffs or nebulizer. |
|Call parent after second dose. Student to go home from school if no relief. |
|Move to red zone if student is in acute distress. |
|If student returns to Green Zone: |
|( Notify parent of incident. Student OK to return to class. |
|( No physical exercise ( Physical exercise, as tolerated |
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|EMERGENCY! |
|Very short of breath., difficulty breathing |
|Constant cough |
|Reliever medications do not help |
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|RED ZONE |
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