Alfatih.org
Virginia Asthma Action Plan
School Division: ________________________________________________________________________
Date of Birth
Effective Dates
Health Care Provider
Provider’s Phone # Fax #
Last flu shot / / /
Parent/Guardian
Parent/Guardian Phone
Parent/Guardian Email:
Additional Emergency Contact
Contact Phone
Contact Email
Asthma Severity:
Intermittent or Persistent: Mild Moderate Severe
Asthma Triggers (Things that make your asthma worse)
□ Colds □ Smoke (tobacco, incense) □ Pollen □ Dust □ Animals:_________________ □ Strong odors □ Mold/moisture □ Stress/Emotions
□Exercise □ Acid reflux □ Pests (rodents, cockroaches) □ Season (circle): Fall, Winter, Spring, Summer □ Other:______________________
Green Zone: Go! —
Take these CONTROL (PREVENTION) Medicines EVERY Day
Always rinse your mouth after using your inhaler and remember to use a spacer with
You have
ALL of these:
your MDI.
Dulera ______ Symbicort ______ Advair ______ , ____ puff (s) ____ times a day
Combination medications: inhaled corticosteroid with long-acting
-agonist
Alvesco _____ Asmanex ____ Azmacort _____ Flovent ____ Pulmicort QVAR ____
Inhaled Corticosteroid or Inhaled corticosteroid/long-acting
-agonist
____ puff (s) MDI ___ times a day
Or ____ nebulizer treatment (s) ___ times a day
Peak flow: _______ to _______
Singulair or __________________________, take ____ by mouth once daily at bedtime
Personal best peak flow:________
For asthma with exercise, ADD: Albuterol or ____________________, _____ puffs with
Yellow Zone: Caution! —
Continue CONTROL Medicines and ADD RESCUE Medicines
You have
ANY of these:
Albuterol or __________________, ____ puffs with spacer every ____ hours as needed
Inhaled
-agonist
Albuterol or _________________, one nebulizer treatment (s) every ____ hours as needed
Inhaled
agonist
Call your Healthcare Provider if you need rescue medicine for more than 24
hours or two times a week, or if your rescue medicine doesn’t work.
Peak flow: _______ to ______
(60% - 80% of Personal Best)
ROL &
ROL & RES
You have
ANY of these:
Albuterol or ______________, __ puffs with spacer
every 15 minutes, for
THREE treatments
Inhaled
-agonist
Albuterol or ____________, one nebulizer treatment
every 15 minutes, for
THREE
Inhaled
-agonist
Call your doctor while administering the treatments.
IF YOU CANNOT CONTACT YOUR DOCTOR:
Call 911 or go directly to the
Peak flow: < _______
Emergency Department NOW!
REQUIRED SIGNATURES:
SCHOOL MEDICATION CONSENT & HEALTH CARE PROVIDER ORDER
I give permission for school personnel to follow this plan, administer medication
CHECK ALL THAT APPLY:
and care for my child and contact my provider if necessary. I assume full responsibility for providing the school with prescribed medication and delivery/
Student instructed in proper use of their asthma medications, and in my
monitoring devices. I approve this Asthma Management Plan for my child.
opinion, CAN CARRY AND SELF-ADMINISTER INHALER AT SCHOOL.
PARENT/GUARDIAN _____________________________
Date ________
Student is to notify designated school health officials after using
inhaler at school.
SCHOOL NURSE/DESIGNEE ________________________
Date ________
Student needs supervision or assistance to use inhaler.
OTHER ______________________________________
Date ________
____ Student should NOT carry inhaler while at school.
CC:
Principal
Cafeteria Mgr
Bus Driver/Transportation
MD/NP/PA SIGNATURE: ____________________________ DATE_______
Coach/PE
Office Staff
School Staff
Blank copies of this form may be reproduced or downloaded from www.virginiaasthma.org
Virginia Asthma Action Plan approved by the Virginia Asthma Coalition (VAC) 4/12
Based on NAEPP Guidelines and modified with permission from the D.C. Asthma Action Plan via District of Columbia
Department of Health, DC Control Asthma Now, and District of Columbia Asthma Partnership
Source: http://www.alfatih.org/wp-content/uploads/2013/10/VAAP.pdf
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