CENTRAL VALLEY SCHOOL DISTRICT #356
ASTHMA HISTORY UPDATEStudent’s Name: _________________________Date of Birth: ____________________School: ________________________________Grade/Teacher____________________Parent/guardian name(s): ___________________________________________________________Home phone: _____________ Work phone: ______________ Cell/pager: __________________Alternate contact: _______________________________ Phone: __________________________Primary Health Care Provider: _________________________Phone: ____________________How many times has this student been seen in the emergency room for asthma in the past year?: __How would you rate the severity of this student’s asthma?(not severe) 1 2 3 456789 10 (severe)How many days would you estimate this student missed last year because of asthma?: ___________Has your child developed any new triggers for his/her asthma in the past year? yes no If yes, describe: ________________________________________________________________________What medications does this student take for asthma (both every day and as needed PRN:Medication NameAmount Delivery Method (inhaler,How Often? Nebulizer, oral, etc.)____________________________________________________________________________________________________________________________________________________________________________________________________________________What herbal remedies, if any, does this student take for asthma?:_________________________ _____________________________________________________________________________Does this student use any of the following aids for managing asthma?: peak flow meter (personal best, if known: ______________) holding chamber spacer holding chamber with mask other (specify): _________________________________________________________________Please check special needs related to your child’s asthma: physical education class recess animals in classroom avoidance of certain foods field trips access to water transportation to and from school observation of side effects from medications otherIf you checked any of the above boxes, please describe needs:________________________________________________________________________________________________________________________________________________________________Parent Signature: __________________________________________Date: _______________Nurse Signature: ___________________________________________Date: _______________3/04 ................
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