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 & HOME Phone #)

Parent/Guardian 1 (Name & WORK Phone #)

Parent/Guardian 1 (Name & CELL Phone #)

Parent/Guardian 2 (Name & HOME Phone #)

Parent/Guardian 2 (Name & WORK Phone #)

Parent/Guardian 2 (Name & CELL Phone #)

Student Medical Report

Asthma

Hypoglycemia

Diabetes

Bee Sting Allergies

Contact Allergies

Food Allergies

Seizures

Other

Allergies/Other

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

List All Allergies

Allergy Information

Life Threatening (Call 911 Immediately

Moderate

Mild

Clear selection

Signs of a Reaction for this Student Include:

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

Action Plan

Steps to be Taken

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

Rate the Severity of his/her Asthma

Not severe

Severe

Clear selection

Triggers for Student's Asthma Attacks

Illness

Emotions

Fatigue

Weather

Medications

Chemical Odor

Cigarettes

Exercise

Smoke

Allergies

Other

List Other

Actions Taken by Student to Relieve Wheezing During an Asthma Attack

Breathing exercises

Rest/relaxation

Drink liquids

Take medication

Inhaler

Nebulizer

Other

List Other

Asthma Medications Student Takes and How Often

Every day (preventative medication)

For wheezing/coughing (emergency medication)

Just before exercise

Only certain times of the year

When ill

Medication to Take at School

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

What side effects does this student suffer from this medication?

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

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

Send me a copy of my responses.

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