Student Asthma Action
Card
Name:____________________________ Grade:_________ Age:______
Teacher: _____________________Room:___________
ID Photo
Parent/Guardian
Name:___________________ Ph (H):________________
Address: _________________________________Ph (W):_______________
Parent/Guardian Name:_____________________ Ph (H):________________
_____________________Ph (W):________________
Emergency Phone Contact #1:______________________ _______________
___________
Name
Relationship
Phone
Emergency Phone Contact
#2:______________________ _______________ ___________
Name
Relationship
Phone
Physician Student Sees for
Asthma:_______________________________ Ph:______________
Other Physician:______________________________________________ Ph:______________
Daily Asthma Management Plan
Identify the things which start an asthma episode (check each that applies to
the student).
___Exercise ___ Strong odors or fumes
____Other_____________________
___Respiratory infections ____Chalk
dust ___Change in temperature
___ Carpets in the room ___Food
___ Animals ___Pollens
___ Molds
Comments:________________________________________________________________
Control of School Environment
(List any environmental control measures, pre-medications, and/or dietary
restrictions that the student needs to prevent an asthma episode.)
_________________________________________________________________________________
_________________________________________________________________________________
Peak Flow Monitoring
Personal Best Peak Flow Number______________________________________
Monitoring Times:_________________ ______________________
____________________________
Daily Medication Plan
Name
Amount
When to Use
1 .__________________
__________________ ____________________
2. __________________ __________________ ____________________
3. __________________ __________________ _____________________
4. __________________ __________________ _____________________
Emergency Plan
Emergency action is necessary
when the Student has symptoms such as_____________________________
_____________________________________ or
has a peak flow reading of_____________________________
Steps to take during an asthma episode:
1. Give medications as listed below.
2. Have student return to classroom if
_________________________________________________________
____________________________________________________________________________________
3. Contact parent if
_______________________________________________________________________
4. Seek emergency medical care if the student has any of the following:
No improvement 15-20 minutes after initial treatment with medication and a
relative cannot be reached.
Peak flow of _____________________________________
Hard time breathing:
Chest and neck are pulled in with breathing.
Child is hunched over.
Child
is struggling to breathe.
Trouble walking or
talking.
Stops playing and can't start activity again.
Lips or fingernails are gray or blue.
IF THE ABOVE HAPPENS, GET
EMERGENCY HELP NOW!
Emergency Asthma Medications
Name
Amount
When to Use
1 ._____________________ ________________________
__________________________________
2._____________________ ________________________
__________________________________
3._____________________ ________________________
__________________________________
4._____________________ ________________________
__________________________________
Comments/Special Instructions
_____________________________________________________________________________________
_____________________________________________________________________________________
For Inhaled Medications
__ I
have instructed (name)__________________________________________________
in the proper way to use
his/her medications. It is my
professional opinion that he/she should be allowed to carry and
use that medication by him/herself.
___ It
is my opinion that _____________________________should not carry his/her inhaled
medication by him/herself.
Physician Signature
_________________________________________ Date ___________________
Parent Signature ___________________________________________ Date
___________________
*Developed by the Asthma and
Allergy Foundation of America (AAFA):
Endorsed by the National Asthma Education arid Prevention Program (NAEPP)