Asthma Action Plan

1.	Student's name:*

2.	Grade:*
	--Please Select--Little WoodlandPre-KindergartenJunior KindergartenSenior Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade

3.	Asthma Triggers* Check all that apply.
	Environmental (pollen, trees, grass, dust, molds)    Cold/flu/upper respiratory infections    Exercise    Temperature extremes    Animals (cats, dogs, etc.)    Emotional stress    Insects (cockroaches, dust mites, etc.)    Other, please specify

4.	Symptoms of asthma flare:* Check all that apply.
	Shortness of breath    Coughing    Wheezing    Chest tightness    Other, please specify

5.	Date of last episode:

6.	Does you student have a rescue inhaler prescribed?
	--None--Yes No

7.	Type of inhaler?
	Type of inhaler? ProAir HFA Ventolin HFA Symbicort Albuterol nebulizer Xopenex HFA Other, please specify

8.	Where will student keep inhaler?*
	Nurse's office (preferred for students 4th grade and younger)    Student's backpack    After school care office (recommended if participating in ASC)    Classroom    Parent will send if needed    Other, please specify

9.	Is your student on maintenance or asthma controller medication? i.e. Singulair, Pulmocort, etc.*
	--Please Select--Yes No

10.	List all asthma maintenance/controller medications:

11.	Is your student on maintenance ALLERGY medications? i.e. Claritin, Zyrtec, Allegra, Xyxal*
	--Please Select--Yes No

12.	List all ALLERGY medications:

13.	YELLOW ZONE (caution zone) If student presents with the following symptoms: *shortness of breath *cough, wheeze, or chest tightness *some difficulty doing usual activities *symptoms of cold or flu Check all that apply.
	Give 2 puffs of rescue inhaler    Call parent to inform of status    Other, please specify

14.	RED ZONE (danger zone) If student presents with the following symptoms: *severe breathing problem *cannot do usual activities * difficulty walking and talking * rescue medication is not helping:* Check all that apply.
	Give 2 puffs of rescue inhaler    Call 911    Contact parent immediately    Other, please specify

15.	Any other information you would like for the nurses to be aware of?

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16.	Parent signature:

17.	Today's date:
	mm/dd/yyyy