Medical Management Plan for Asthma

Student Information

School Year: __________________

Student Name: __________________

Date of Birth: __________________

Physician’s Name: __________________

Phone #: __________________

Address: __________________

Fax #: __________________

Allergies

List Known Allergies:

___________________________________________________________________________________________

Asthma Triggers

Identify the things that start an asthma episode (check all that apply to the student):

• Exercise
• Strong odors or fumes
• Respiratory infections
• Chalk dust
• Change in temperature
• Carpets in the room
• Animals
• Pollens
• Food
• Molds
• Other: __________________

Daily Medication Plan

Name of Medication	Amount/Dose	When to Use
1. __________________	__________________	__________________
2. __________________	__________________	__________________
3. __________________	__________________	__________________

Emergency Action

Emergency action is necessary when the student has symptoms such as:

___________________________________________________________________________________________

Steps to Take During an Asthma Episode

Give emergency medications listed below. Seek emergency medical care if the student has any of the following:

• No improvement 15-20 minutes after initial treatment with medication, and a relative cannot be reached.
• Continued difficulty breathing.
• Trouble walking or talking.
• Stops playing and cannot start activity again.
• Lips or fingernails are gray or blue.

Emergency Asthma Medications

Name	Amount/Dose	When to Use
1. __________________	__________________	__________________
2. __________________	__________________	__________________
3. __________________	__________________	__________________

Nursing Services Recommendation

Nursing services are recommended for the care of this student during the school day.

Signatures

Physician’s Signature: __________________

Date: __________________

Asthmatic Students: Possession of Inhalers

Florida law states an asthmatic student may carry a prescribed metered dose inhaler on his or her person while in school with approval from his or her parents and physician.

The above named child may carry and self-administer his or her metered dose inhaler.

Parent/Guardian Signature: __________________ (Required)

Date: __________________

Physician’s Signature: __________________ (Required)

Date: __________________

Continued Asthma Plan

For (Student NAME)

Is your child compliant with their current treatment regime? Yes / No

Does your child function independently with medication administration? Yes / No

Are there any activity restrictions for your child? Yes / No

If yes, please list: __________________

Authorization for Health Care Provider and School Nurse to Share Information

I authorize my child’s school nurse to assess my child as it relates to his or her special health care needs and to discuss these needs with my child’s physician as needed throughout the school year. I understand this is for the purpose of generating a health care plan for my child. I understand I may withdraw this authorization at any time and that this authorization must be renewed annually.

As the parent or guardian of the student named above, I request that the principal or principal’s designee assist in the administration of medication or treatment prescribed for my child.

I understand that under provisions of Florida Statute 1006.062, there shall be no liability for civil damages as a result of the administration of medication when the person administering such medication acts as an ordinarily reasonable, prudent person would have acted under the same or similar circumstances. I also grant permission for school personnel to contact the physician listed above if there are any questions or concerns about the medication. I have read the guidelines and agree to abide by them. I authorize the physician to release information about this condition to school personnel.

Parent/Guardian Information

Parent/Guardian Signature: __________________

Print Name: __________________

Date: __________________

Parent/Guardian Cell: __________________

Work: __________________

Parent/Guardian Cell: __________________

Work: __________________