RAYMOND ELEMENTARY SCHOOL
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School Asthma Plan
Student’s Name ______________________________ Date ___________________
Teacher’s Name ______________________________ Age ________________
School ______________________________________
Instructions to School
1.If coughing or wheezing, give:
□ Albuterol 2-4 puffs with/without spacer and notify parent/guardian
□ Albuterol 1 treatment via nebulizer and notify parent/guardian
2. Pre-Medication, give:
□ Albuterol 2-4 puff with/without spacer 15-30 minutes prior to exercise
□ Albuterol 1 treatment via nebulizer 15-30 minutes prior to exercise
3. □ Recommend that student be allowed to carry and self- administer all asthma medications
4. □ Recommend that school nurse/personnel administer asthma medications and notify parents
5. Other instructions: ____________________________________________________
_______________________________________________________________________
Parent Signature: _____________________________________________________
Physician Signature: __________________________________________________
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