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Student’s Name: Date of Birth: Grade: ID : School: Teacher: Age at on set: Contact Information Mother/Guardian: Telephone: Home Work Cell Father/Guardian: Telephone: Home Work Cell Student’s Doctor/Health Care Provider: Address: Telephone: Emergency Number: Other Emergency Contacts (Relationship): Telephone: Home Work Cell Asthma Triggers: (circle those that apply Foods: Animals Insect Sting/Bee Chalk Dust Weather Change Dust Mites Exercise Latex Molds Pollens Respiratory Illness Smoke Strong Odors Other: If Exercise: Pre-medication (dose and frequency) Exercise medifications 1 Asthma Episode Indicators:      Shortness of breath – especially with exertion Wheezing – a whistling or hissing sound when breathing out Coughing – may occur after exercise or when exposed to cold, dry air Chest tightness – may occur with or without the above symptoms Indicators specific to THIS STUDENT: Steps to take during an asthma episode:         Notify school health office

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Asthma Medical Management Plan

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