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PUPIL HEALTH - ASTHMA RECORD
An inhaler will only be accepted by Balcombe School for use by your child if the following form is completed in full.
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* Indicates required question
Name of Child
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Class
*
Lake
Coombe
Forest
Spring
Mill
Preadmission
Year Group
*
Reception
Year 1
Year 2
Year 3
Year 4
Year 5
Year 6
Preadmission
Does your child need an inhaler kept at school?
If yes, by submitting this form you undertake to keep the school provided with an in-date inhaler
Yes
No
Clear selection
Please provide full information of your child's current treatment
Ensure you provide the name of the inhaler
Your answer
State the required dose
Ensure you advise the number of puffs required
Your answer
Please choose the appropriate option for your child
*
My child requires a spacer and requires a member of staff to assist with administration
My child does not require a spacer but requires assistance with administration
My child can administer his/her own medication under supervision
My child may keep his/her inhaler and administer as required
What triggers your child's asthma?
*
Your answer
Does your child require a blue inhaler before exercise/PE?
If so, state dose
Yes
No
Other
Clear selection
EMERGENCY ADMINISTRATION
Do you give consent for the following treatment to be given to your child as recognised by Asthma specialists in an emergency?
•
Give 6 puffs of the blue inhaler (via a spacer if necessary)
•
Reassess after 5 minutes
•
If child still wheezy or appears breathless administer a further 4 puffs of the blue inhaler
•
Reassess after 5 minutes
•
If symptoms are not relieved with 10 puffs of blue inhaler this should be viewed as a serious attack
•
School will call an ambulance and then call parent
•
Whilst waiting for ambulance we will continue to give 10 puffs of reliever inhaler every few minutes
Declaration of agreement to above emergency action
I authorise the emergency procedures above
I do not agree to administration by the school as set out above and wish to discuss the matter with the headteacher
Name of the person completing form
*
I confirm that I am the person with parental responsibility
Your answer
Date
*
MM
/
DD
/
YYYY
Submit
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