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: IntermittentorPersistent: 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