20 ENDICOTT ROAD TOPSFIELD, MASSACHUSETTS 01983 (978) 887-2323
Student
______________________________________Date of Birth __________Grade__9___
Date of
Diagnosis______________How often do the asthma attacks
occur?_________________Date of Last Asthma attack____
Has student been
treated in the hospital for asthma in the past year? □
No
□Yes When
___________________________
Asthma
severity: □ mild
intermittent □ mild
persistent □ moderate
persistent □ severe persistent
Is a peak flow
meter used? □ No □Yes
Best flow rate is _____________________
CHECK THE CONDITIONS THAT
USUALLY BRING ON THIS STUDENT’S ASTHMA ATTACK:
respiratory
infection ______________________
exposure to cold air _______________ emotional stress ______________________
exercise(
e.g. after running, etc.)
________________________________________________________________________________
odors (e.g.
perfume, smoke, etc) ___________________________________________________________________________________
allergic reaction to (e.g. mold, animals, etc.) ___________________________________________________________________________
other (describe)
_____________________________________________________________________________________________
CHECK
THE SIGNS THAT ARE USUALLY PRESENT IN THIS STUDENT’S ASTHMA ATTACK:
coughing
□
wheezing □
shortness of breath □ feeling frightened □
bluish color of skin/nails
□ unable to speak sentence without taking a breath □ other (describe) __________________________________________________
Special needs,
activity restrictions/ adaptations or protective equipment needed at
school? No Yes (describe)
_______________________
______________________________________________________________________________________________________________
THE
USUAL PROCEDURE FOLLOWED AT SCHOOL INCLUDES:
1.
Allow student
to use his/her prescribed asthma medication with assistance given as needed.
2.
Encourage
student’s relaxation (e.g. slow, deep breathing, sipping warm fluids).
3.
Stay with
student; monitor for symptoms.
Students are
encouraged to carry their own inhalers and it is recommended that a spare
inhaler be kept in the nurse’s office. I give permission for my child to carry
the inhaler listed in the medications table on the reverse side of this form.
We understand that he/she must follow the rules below:
a) he/she must
demonstrate the correct use of the inhaler to the school nurse
b) he/she agrees never share the inhaler with another student
c) he/she agrees that after two puffs, if there is not marked improvement, he/she will go the nurse’s office immediately
I give permission for the school nurse to speak with my student’s doctor regarding this diagnosis and to share with necessary school personnel information included in this document Yes_____ No______
or on school
related events. Yes___ No___
Name:__________________________Relation:___________Cell Phone_____________Home/work_________
Name__________________________ Relation____________Cell Phone_____________Home/work________
REMEMBER TO ADVISE
THE SCHOOL IMMEDIATELY OF CHANGES IN PHONE NUMBERS, ADDRESS, RESPONSIBLE
EMERGENCY CONTACT PERSON, DOCTOR, HOSPITAL PREFERENCES.
Masconomet has a policy regarding taking
medications at school. Please call the
school nurse for direction.
Tests and activity restrictions occurring during school hours require written direction from your child’s doctor.