Site:______
Barren River District Health Department
Please fax back to:______
Barren, Butler, Edmonson, Hart, Logan, Metcalfe, Simpson, Warren Counties
Primary Care Provider Authorization (PCP): Asthma/Allergy (Side One)
Student Name: ______Date of Birth: ______
School: ______Hospital of Choice:______
Does this child have ASTHMA? ____ YES ____ NO
What things may bring on this child’s asthma?
__ Pollens __ Dust __ Animals __ Exercise __ Foods __ Illness __ Other______
Asthma SYMPTOMS may include: Coughing, Shortness of Breath, and Wheezing.
Please list any other symptoms specific for this child: ______
*****Please refer to Emergency Plan of Action on Side Two for symptoms indicating an emergency asthma situation. *****
Asthma Medications AT SCHOOL:
Order will be for current school year.
__ Inhaler(specify name):______Dosage:______puffs every ____ hours____scheduled and/ or _____ as needed ___ minutes prior to exercise __ Other______
__ Nebulizer(specify name): ______Dosage:_____every _____hours ______scheduled and/or _____as needed ______minutes prior To exercise___Other ______
*****If student needs prn inhaler more than twice a week, please notify parent.*****
Is this student trained and capable of carrying their own inhaler and using it on their own? ___ YES ___ NO
If student not carrying inhaler, it is to be kept:
______In front office_____student classroom _____ nurse’s office Other______
Does this child have ALLERGIC REACTIONS? __ YES __ NO
What things cause this student’s allergic reaction?
__ Medications __ Stinging Insects __ Other ______
SYMPTOMS of the allergic reaction for this child:
______Itching/Swelling of Lips, Mouth, Tongue, Throat ______Hives/Rash ______Nausea/Vomiting/Stomach Cramps ______Shortness of Breath ______Wheezing ______Coughing ______Dizziness ______Unconsciousness Other ______
Medications AT SCHOOL:
___Benadryl ______mg every ______hours____ at onset
___EpiPen Jr. __ Epi Pen __ Twinject ___ Auvi-Q
___ Give Epipen/Twinject/ Auvi-Q per md order at onset of allergic reaction and/or exposure to allergy trigger unless otherwise indicated.
___ Other instructions______
***IF 2nd DOSE OF AUVI-Q, TWINJECT OR 2nd EPIPEN NEEDED, give: ____ Minutes after 1st Dose
May student carry own Auvi-Q/ EpiPen/Twinject and use on their own? __ YES __ NO
If student not carrying Auvi-Q/ EpiPen/Twinject, it is to be kept: ______In front office_____ student classroom _____Nurse’s office Other ______
Does this child have a FOOD ALLERGY? __ YES __ NO Please list any food allergies:______
Is student Lactose Intolerant? __ YES __ NO
*****Please attach Special Food Order Form for state of KY to be forwarded to the cafeteria*****
EMERGENCY PLAN OF ACTION
1. Follow orders above for Asthma and/or Allergy treatments and medications.
2. If student is hunched over and/or having difficulty breathing, walking or talking, blue fingernails or lips, and/or medications not helping, call 911.
3. Notify school personnel trained in CPR/first aid to respond and initiate CPR if needed prior to EMS arrival.
4. Notify parent/guardian.
5. If EMS is called, the student must be transported via EMS to emergency facility, or parent/guardian must sign release with EMS and then parent/guardian assumes responsibility for student. The student may not return to school that day. When student is transported via EMS, school staff must accompany student unless parent and/or emergency contact accompanies them.
6. If student requires medical treatment while on the bus, the bus driver will contact 911.
7. Other: ______
______
Printed Name of MD, APRN, or PA Telephone Number Fax Number
______
Signature of MD, APRN, or PA Date
I give permission for (name of child) ______to receive the above stated medication at school according to standard school policy. I release the ______School Board and its employees from any claims or liability connected with its reliance on this permission
______
Signature of Parent/Guardian Telephone Number Date
This order and plan of care is valid for current school year. Parent required to supply all medications.
Reviewed per School Nurse______Copy to pertinent school staff______
(3-2014) 6A-1
Site:______
(3-2014) 6A-1