Asthma/Allergy Reaction Treatment Plan

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Email *

Student's Name *

Student's Date of Birth *

Student's Grade *

Physician's Name & Phone # *

Hospital Preference *

Parent/Legal Guardian's Daytime Phone Numbers:

Please enter Parent(s) or legal Guardian(s) contact name & phone numbers that may apply

Parent/Guardian 1 (Name & Phone #) *

Parent/Guardian 2 (Name & Phone #)

Student Medical Report

Medical Condition: *

Asthma

Hypoglycemia

Diabetes

Bee Sting Allergies

Contact Allergies

Food Allergies

Seizures

Other

Required

Allergies/Other

If allergies is checked, please list all allergies or other option

Severity of his/her Asthma *

Life Threatening (Call 911 Immediately)

Moderate

Mild

Signs of a Reaction for this Student Include:

Reaction: *

Swelling at site of sting or contact

HIves

Difficulty breathing

Hoarseness

Nausea

Diarrhea

Racing pulse

Swelling beyond area of sting or contact

Itching sensation

Swelling of lips

Hacking cough

Abdominal cramps

Shortness of breath

Passes out

Rash over large area or entire body

Tightness in throat

Swelling of tongue

Tightness in chest

Vomiting

Wheezing

Other:

Required

List Other

Action Plan

Steps to be Taken: *

Action Plan - Please List Steps to be Taken Below

All medications to be used in the Action Plan are to be provided by Parent/Guardian with the appropriate Authorization for Administration of Medication form completed and signed

Asthma Information

Triggers for Student's Asthma Attacks *

Illness

Emotions

Fatigue

Weather

Medications

Chemical Odor

Cigarettes

Exercise

Smoke

Allergies

Other

Required

List Other

Asthma Attack

Steps to take:

Breathing exercises

Rest/relaxation

Drink liquids

Take medication

Inhaler

Nebulizer

Other

List Other

Asthma Medication to Take & Frequency at School

What medication will this student need to take in school? (please list name and when taken) *

How Often: *

Every day (preventative medication)

For wheezing/coughing (emergency medication)

Just before exercise

Only certain times of the year

When ill

Required

What side effects does this student suffer from this medication? *

PLEASE NOTE--911 will be called if...

- An Epi Pen or Epi Pen Jr. is used.
- Signs or symptoms of a reaction persists or worsens even after the ACTION PLAN steps have been taken.
- The school personnel believe the student is in immediate danger.

PARENT SIGNATURE - Please read before signing

I certify that the information given above is complete and accurate. I acknowlede that I have a continuing obligation to inform the school of any changes in this student's health status that are relevant to the information requested by this form. I understand and agree that the above information may be shared with school staff. I understand that if my child receives medications at school, the signed Authorization for Administration of Medication needs to be completed and signed. This authorization shall continue until the last day of this school year, or util I notify the school (in writing), that I revoke the authorization.

I understand that this electronic signature below provides the same legal standing as a handwritten signature

Parent/Legal Guardian's Signature: *

Date of Parent/Legal Guardian' Signature: *

YYYY

Medication Consent Form

IMPORTANT: A Medication Consent Form will also need to be completed and submitted that authorizes the staff to administer any medication to be given to your child.

Please click on the link ON THE CONFIRMATION PAGE once you have submitted this form, and complete the Medication Consent Form.

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