Asthma Information Form

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Child's Name *

Class *

Does your child need an inhaler in school?

Yes

Clear selection

Please provide as much information as possible on your child's current treatment. Include the name, type of inhaler, dose and how many puffs? *

What triggers your child's asthma? *

Symptoms *

Does your child need a blue inhaler before doing excercise/PE? If so how many puffs? *

It is advisable to have a spare inhaler in school. Spare inhalers may be required in the event that the first inhaler runs out, is lost or forgotten. Inhalers must be clearly labelled with your child's name (pharmacy label) and must be replaced before their expiry date.

Please choose one of the following options:

My child requires and inhaler and spacer and I have signed these in at the school office.

My child does not require a spacer/inhaler.

I agree to ensure that my child has an in-date inhaler and spacer (if prescribed) in school.

Yes

Clear selection

To give permission for your child to use the emergency salbutamol inhaler in school please click on the following link https://forms.gle/nxC85YMYm9jzx51d8

Name of person completing this form. *

Date completed: *

YYYY

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This form was created inside of Sacred Heart Catholic Primary School.

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