ASTHMA UPDATE
According to our school health records, your child has (or has had) asthma.  
Please complete this form to update us on his/her current health status.  Thanks.

  STUDENT NAME: _____________________________________  GRADE:_____________

  Physician treating child’s asthma: ___________________________  Phone _____________

  1.      When was the last time this physician saw your child? ____________________________

  2.      When was your child’s asthma first diagnosed? _________________________________

  3.      Does your child require medication?
         Not anymore ______                           Only with a cold ______
         Daily ______                                       Only during allergy season ______
         Prior to exercise only ______               Other _________________________________

  4.      What medication(s) does your child use and how often? __________________________
         ________________________________________________________________________
        (Any prescription medication requires written physician order, and parent signature

   5.      Has your child needed emergency care for his/her asthma?  _______________________
         When/what treatment was needed? ___________________________________________

   6.      Does your child have any allergies? __________  Please specify ____________________
         ________________________________________________________________________

   7.      Does your child need to be excused from strenuous activity at any time? ____________
         ___________________________________________________________________________

   8.      Please outline a step–by–step emergency plan for your child should he/she have distress at school.

  1. _______________________________            3. ______________________________

   2. _______________________________            4. _______________________________
 
   COMMENTS: ___________________________________________________________

    Parent/Guardian Signature: _____________________________ Date: _______________

PLEASE RETURN TO THE HEALTH OFFICE

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