Asthma and/or Inhaler Form

Student Last Name*

Answer required for "Student Last Name"

Student First Name*

Answer required for "Student First Name"

Parent's Name*

Answer required for "Parent's Name"

Parent's Phone Number*

Answer required for "Parent's Phone Number"

Address*

Answer required for "Address"

Email*

Answer required for "Email"

Physician Treating Child's Asthma or Prescribing Inhaler*

Answer required for "Physician Treating Child's Asthma or Prescribing Inhaler"

Physician's Phone Number*

Answer required for "Physician's Phone Number"

Has your child been diagnosed with asthma?*

Answer required for "Has your child been diagnosed with asthma?"

Yes

Briefly describe what causes the child's asthma symptoms:*

Answer required for "Briefly describe what causes the child's asthma symptoms:"

Does he/she do breathing exercises that are helpful in managing the asthma?*

Answer required for "Does he/she do breathing exercises that are helpful in managing the asthma?"

Yes

In which sports can the child fully participate?*

Answer required for "In which sports can the child fully participate?"

Does exercise induce episodes of asthma?*

Answer required for "Does exercise induce episodes of asthma?"

Yes

If you answered "Yes" to the previous question, please list the types of exercise below:

Answer required for "If you answered \"Yes\" to the previous question, please list the types of exercise below:"

Do certain weather conditions affect your child's asthma?*

Answer required for "Do certain weather conditions affect your child's asthma?"

Yes

If you answered "Yes" to the previous question, please list the types of weather below:

Answer required for "If you answered \"Yes\" to the previous question, please list the types of weather below:"

Name the medications taken routinely, the dosage, how often taken, when, and under what circumstances additional doses should be given.*

Answer required for "Name the medications taken routinely, the dosage, how often taken, when, and under what circumstances additional doses should be given."

Does your child suffer any side effects to these medications?*

Answer required for "Does your child suffer any side effects to these medications?"

Yes

If you answered "Yes" to the previous question, please list the side effects below:

Answer required for "If you answered \"Yes\" to the previous question, please list the side effects below:"

Does your child understand asthma and what he/she should do to manage it?*

Answer required for "Does your child understand asthma and what he/she should do to manage it?"

Yes

How do you want the school to treat an episode of asthma if it should occur?*

Answer required for "How do you want the school to treat an episode of asthma if it should occur?"

Approximately how often does the child have an acute episode?*

Answer required for "Approximately how often does the child have an acute episode?"

If the child does not respond to medication, what action does the parent/guardian advise school personnel to take?*

Answer required for "If the child does not respond to medication, what action does the parent/guardian advise school personnel to take?"

Legal Guardian's Signature*

Signature Required

Please fix the highlighted areas below before submitting.

Asthma and/or Inhaler Form