Child Name:____________________________
Date of Birth:_______________

I authorize the exchange of medical information about my child’s asthma between the Physician’s
office and school nurse.
Parent or Guardian signature: _____________________________________________
Date:__________Parent or Guardian tel.# home: ____________________ work:_____________________ cell phone:____________________Physician/Healthcare Provider Name: Parent concerns: TO BE COMPLETED BY STUDENT’S PHYSICIAN/HEALTHCARE

Provider name: ____________________________ Tel.#:
__________________ Fax# __________________
NO changes from previous plan.
Peak Flow
Child’s predicted, or personal best peak flow: _______ (Date:
Child's Green Zone: ______________ Yellow Zone: _______________ Red Zone:
Preventive (Controller) meds:
Quick relief meds (check the appropriate quick relief med, circle device, list dose/ frequency):
 Albuterol (Proventil, Ventolin)  Pirbuterol (Maxair)  4Inhaler with spacer OR nebulizer 4 Dose/Frequency: ______________________________________________ Allergies /Triggers for asthma: OR  None known
 Avoid animals  Other triggers to avoid: ____________________________________________________________________________ _____________________________________________________________________________ Exercise Pretreatment Instructions (check all that apply)
 Give 2 puffs of quick relief inhaler 15 minutes prior to recess/ physical education and/ or __________________________  May repeat 2 puffs of quick relief inhaler if symptoms recur with exercise, or ____________________________________  Measure Peak Flow prior to recess / physical education; restrict aerobic activity when child’s Asthma Exacerbation Treatment Instructions:
YELLOW ZONE: If child is coughing, wheezing or short of breath, and/or peak flow is in
Yellow Zone:
Give 2 puffs of child’s quick relief inhaler with spacer. May be repeated in 10 minutes if __________________________________________________________________________________ RED ZONE: If child is in respiratory distress, and/or peak flow is in Red Zone:
 Give 4 puffs quick relief inhaler (or nebulizer treatment), and call parent and Healthcare MAINE SCHOOL ASTHMA PLAN INSTRUCTIONS
Every student with asthma in grades kindergarten through twelve should
have a current Maine School Asthma Plan completed and signed by their
physician (or other health care professional) and kept on file in the school
nurse’s office. The form must also be signed by a parent/guardian. The plan
should be updated each year or when there are major changes to the plan
(such as in medication type or dose). The physician’s office is encouraged
to fax the plan to the student’s school nurse.

The school plan is intended to strengthen the partnership of families,
healthcare providers and the school. It is based on the NHLBI Guidelines for
Asthma Management. (For more information contact the school nurse or
HYPERLINK http://www.nhlbi/nih/gov
Most students are capable of carrying and using their quick relief inhaler by
themselves. The student, student’s parents, school nurse and healthcare
provider should make this decision. The school nurse should also evaluate
technique for effective use.
This indicates poor control of asthma. Healthcare providers should check this
box to be notified.
PEAK FLOW ZONES (based on student’s personal or predicted best):
Green zone: Peak flow 80-100%
Symptoms and/or use of quick relief medication < 2 times a week.
Use daily controller medication at homeFull participation in physical education and sports Yellow zone: Peak flow 50-80%
Has symptoms or needs quick relief medication >2 times a weekNeeds quick relief medication and further observation by school nurse; notify parentsAttend physical education but restrict strenuous aerobic activity Red zone: Peak flow <50%
Symptoms may include shortness of breath, retractions, difficulty talking or walking, quick relief medication not effectiveRequires immediate action, close monitoring and notification of parent and healthcare provider School Letterhead
Please complete attached School Asthma Plan if your child
has asthma (sometimes called reactive airways disease) and/or
has an inhaler at school
The purpose of this Plan is to keep your child, who has asthma, safe during the school day. Please complete the first section and send the Plan back to the school nurse. The school nurse will then FAX the Plan to your doctor for completion. If you prefer, you can give the Plan directly to your doctor and ask him/her to complete it and send it back to your school nurse.
The best way to keep your child with asthma safe is by having a current, updated Plan available on file at school. Please call the school nurse at your school if you have questions. Thank you for your help.
Maine Asthma Council
For additional copies of this form, call American Lung Association of Maine at 1-800-499-LUNG School:_______________________________
Teacher:_____________________ Rm #:____
School Nurse:

School tel:



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