Parent/Guardian Questionnaire for Students with Asthma

Parent/Guardian Questionnaire for Students with Asthma

Student Name___________________________________School Year_______________

Grade _____________Homeroom Teacher _____________________________________

Dear Parent/Guardian,

You noted on the emergency card that your child has asthma. In order to give the appropriate care, we request that you complete this form and return it to the school nurse.

This information will be used to develop an emergency action plan for your child that will be shared with appropriate school staff. If there is any change in this information during the school year, please notify the school nurse in writing.

Thank you,

School Nurse_____________________________________________________________

1. Briefly describe what triggers your child’s asthma symptoms and presenting symptoms

_______________________________________________________________________

_______________________________________________________________________

2. Does your child require treatment before exercise? _____ Yes _____ No

3. Does exercise trigger asthma symptoms? Circle all that apply

Cough Wheeze Shortness of Breath Chest Tightness Chest Pain

4. Do certain weather conditions affect your child's asthma? (List)____________________________________________________________________

5. Do you have an asthma management plan? If yes, please give copy to your school nurse

DAILY MEDICATION / NAME OF RX DOSAGE WHEN TO USE

1.___________________________________ __________ ______________

2.___________________________________ __________ ______________

EMERGENCY ASTHMA MEDICATIONS DOSAGE WHEN TO USE

1._____________________________________ __________ ______________

2._____________________________________ __________ ______________

Name of Physician________________________________________Phone___________

Signature of Parent/Guardian________________________________Date____________