Gloucester.schooldesk.net

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://gloucester.schooldesk.net/Portals/Gloucester/District/docs/Safety/VAC_asthma_action_plan_5-15-12_final1.pdf