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Asthma Information FORM
Please complete the form below for your child
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Email
*
Your email
Child's first and last name
*
Your answer
Is your child currently under care for Asthma? If the answer is No, you are done with this survey( please scroll to bottom and submit if answer is No)
*
Yes
No
Is your child taking DAILY medications for his/her asthma? (to prevent asthma flare ups)
Yes
No
Clear selection
If taking DAILY medications or asthma, please indicate the name of the medication
Your answer
Is your child prescribed a RESCUE inhaler or nebulizer for use at home?
inhaler
nebulizer
both
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If RESCUE inhaler used, what is the name of the medication?
Your answer
Does your child use a spacer for the inhaler?
Yes
No
Sometimes
Clear selection
If your child uses a nebulizer, what is the name of the medication?
Your answer
Does your child carry a RESCUE inhaler in school?
Yes
No
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What symptoms does your child have when his/her asthma is triggered? (Please check all that apply)
cough
shortness of breath
wheezing
chest tightness
rapid breathing
feeling weak or tired
Other:
What triggers your child's asthma?
Your answer
Has your child been to the ER or been hospitalized for his/her asthma?
No, my child has never been to the ER or hospitalized for asthma
ER visits
Hospitalized
both
Does your child have an asthma action plan?
Yes
No
Clear selection
Do you have any questions for the School Nurse?
Yes
No
Clear selection
Send me a copy of my responses.
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