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Virginia Asthma Action Plan
School Division: ________________________________________________________________________
Date of Birth
Health Care Provider
Provider’s Phone # Fax #
Last flu shot / / /
Additional Emergency Contact
Intermittent or Persistent:
Mild Moderate Severe
Asthma Triggers (Things that make your asthma worse)
□ Colds □ Smoke (tobacco, incense) □ Pollen □ Dust □ Animals:_________________ □ Strong odors □ Mold/moisture □ Stress/Emotions
□Exercise □ Acid reflux □ Pests (rodents, cockroaches) □ Season (circle): Fall, Winter, Spring, Summer □ Other:______________________
Green Zone: Go!
— Take these CONTROL (PREVENTION) Medicines EVERY Day
Always rinse your mouth after using your inhaler and remember to use a spacer with
You have ALL
Dulera ______ Symbicort ______ Advair ______ , ____ puff (s) ____ times a day
Combination medications: inhaled corticosteroid with long-acting
Alvesco _____ Asmanex ____ Azmacort _____ Flovent ____ Pulmicort QVAR ____
Inhaled Corticosteroid or Inhaled corticosteroid/long-acting
____ puff (s) MDI ___ times a day Or
____ nebulizer treatment (s) ___ times a day
_______ to _______
Singulair or __________________________, take ____ by mouth once daily at bedtime
Personal best peak flow:________
For asthma with exercise, ADD:
Albuterol or ____________________, _____ puffs with
Yellow Zone: Caution!
— Continue CONTROL Medicines and ADD RESCUE Medicines
You have ANY
Albuterol or __________________, ____ puffs with spacer every ____ hours as needed
Albuterol or _________________, one nebulizer treatment (s) every ____ hours as needed
Call your Healthcare Provider if you need rescue medicine for more than 24
hours or two times a week, or if your rescue medicine doesn’t work.
_______ to ______
(60% - 80% of Personal Best)
ROL & RES
You have ANY
Albuterol or ______________, __ puffs with spacer every 15 minutes
, for THREE
Albuterol or ____________, one nebulizer treatment every 15 minutes
, for THREE
Call your doctor while administering the treatments.
IF YOU CANNOT CONTACT YOUR DOCTOR:
Call 911 or go directly to the
Peak flow: <
Emergency Department NOW!
SCHOOL MEDICATION CONSENT & HEALTH CARE PROVIDER ORDER
I give permission for school personnel to follow this plan, administer medication
CHECK ALL THAT APPLY:
and care for my child and contact my provider if necessary. I assume full responsibility for providing the school with prescribed medication and delivery/
Student instructed in proper use of their asthma medications, and in my
monitoring devices. I approve this Asthma Management Plan for my child.
opinion, CAN CARRY AND SELF-ADMINISTER INHALER AT SCHOOL.
Student is to notify designated school health officials after using
inhaler at school.
SCHOOL NURSE/DESIGNEE ________________________
Student needs supervision or assistance to use inhaler.
____ Student should NOT carry inhaler while at school.
MD/NP/PA SIGNATURE: ____________________________ DATE_______
Blank copies of this form may be reproduced or downloaded from www.virginiaasthma.org
Virginia Asthma Action Plan approved by the Virginia Asthma Coalition (VAC) 4/12
Based on NAEPP Guidelines and modified with permission from the D.C. Asthma Action Plan via District of Columbia
Department of Health, DC Control Asthma Now, and District of Columbia Asthma Partnership
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