Asthma Inhaler Administration Authorization Form Student’s ...
Asthma Inhaler Administration Authorization Form
Student's Name:_____________________________ DOB: ___________Grade: ___________
For the student to receive the symptom-relieving medication for asthma: Asthma inhaler administration authorization form will be completed and signed by parent and medical provider. Form will be given to school district administrator or school nurse. Asthma inhaler medication will have student's name, medication, directions for use, and date. Authorization of asthma-relieving medication will be updated annually.
The student has the skill, knowledge, and my authorization to use an asthma-relieving medication in the following manner:
____ Student may carry and self-administer asthma-relieving medication. Student will seek the care of school personnel if medication is not successfully controlling his/her asthma.
____ Student needs assistance with administration of his/her asthma-relieving medication with the medication available as needed in the health office.
Asthma symptoms requiring medication include: cough, wheeze, chest tightness, or difficulty breathing.
Drug name (circle) Metered dose inhaler: Albuterol: Ventolin/ProAir/Proventil Levalbuterol: Xopenex
Dosage
2 puffs inhaled
via spacer
Frequency
Every 4 hours as needed 20 minutes prior to exercise
Nebulizer treatment: Albuterol/Xopenex
1 vial inhaled
Every 4 hours as needed 20 minutes prior to exercise
Side effects of albuterol include increased heart rate and jitteriness. School personnel may contact the physician for clarification of any issue relating to this medication. These instructions apply for the duration of the school year.
Physician name: Physician signature:
Office phone: 724-719-2441 Office address: 100 Bradford Road
Suite 410 Wexford, PA 15090 Date:
Parent/Guardian signature
Date:
School Administrator Authorization: _____________________________ Date: _____________
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