Learn about asthma triggers, treatment options, and more. Massachusetts asthma action plan personal best peak flow. This form, when completed by health care providers, gives parents and school personnel a written asthma management plan for children. Asthma triggers try to stay away from or control these things. Asthma action plan national heart, lung, and blood institute. Perform spirometry at baseline and at least every 1 to 2 years for patients 5 years of age. In the 4 stage plan there is an extra step giving patients the option of increasing the dose of ics inhaled corticosteriod. Asthma action plan and informational materials asthma clinical guideline tool. Swelling or inflammation in the linings of the airways. This could include teachers, school nurses, and after school care staff. Before taking this form to your health care provider, complete the top left section with. Here is a sample asthma action plan you can use for students in school. See the reverse side for things you can do to avoid your asthma triggers. Breathing is easy no cough or wheeze can work and play can sleep all night.
The smart plan is used only with the single icslaba maintenance and reliever therapy. Our library includes some of the many different written asthma action plans available. Electronic, fillable pdf versions of asthma action plans. Have the following written down and kept close at hand in case of an emergency. Asthma forms this form must be completed by a medical provider to authorize administration of asthma medications. My asthma action plan times per day every day take only noas needed see below starting in yellow zone or before excercise times per day every day times per day every day 2 puffs 46 puffs 1 nebulizer treatment gargle or rinse mouth after use special instructions when i am doing well be careful ask for help asthma triggers check all that. Name date next asthma checkup due doctors contact details emergency contact details name phone relationship asthma action plan take this asthma action plan with you when you visit your doctor. Use poison baits, powders, gels, or paste for example, boric acid. Put a check next to the triggers that you know make your asthma worse and ask your doctor to help you find out if you have other triggers as well. To access the various versions of the asthma action plans, please utilize the links below. For more information contact the asthma society of canada at. Nonenglish action plans for healthcare professionals asthma uk. Asthma action plan name date of birth gradeteacher.
Everyone with asthma needs his or her own asthma action plan. Asthma action plan name school dob health care provider providers phone parentresponsible person parents phone additional emergency contact contact phone asthma severity see reverse side asthma triggers identified things that make your asthma worse. The guidelines recommend that all children and adults with asthma have a written asthma action plan, developed jointly with their healthcare provider. The asthma action plan should be used as an education and communication tool between the provider and the patient and his or her family. All of our non english asthma action plans contain information standardaccredited advice and their translation has been approved by multilingual professionals. The student above has been instructed by me in the proper way to use hisher medications. Health forms and regulations prince william county public. Asthma action plan provider instructions at initial presentation, determine the level of asthma severity level of severity is determined by both impairment and risk and is assigned to the most severe category in which any feature occurs. Assess asthma control at every visit by selfadministered standardized test or verbal history. To request a supply of hard copy asthma action plans, please fill out our online form or complete the order form pdf or word and submit it via email of fax. Allergens animal dander some people are allergic to the flakes of skin or dried saliva from animals with fur or feathers.
Asthma action plan you can use the colors of a traffic light to help learn about your asthma medicines. Your goal is to prevent and control your asthma attacks. An asthma action plan also called a management plan is a written plan that you develop with your provider to help control your asthma. Management of epileptic seizure in the school setting reg 7577 attachment i. Maintaining good daytoday asthma control is the key to keeping symptoms at bay and preventing asthma attacks. Adapted from finger lakes asthma action plan and nhlbi revised 10. Action plans are available in english and te reo maori. Asthma action plans national asthma council australia.
National heart, lung, and blood institute asthma action plan external icon. Take a photograph of it and keep it on your phone you. I understand that the medication must have a pharmacy label with the name of the student and the health care provider. Asthma action plan library national asthma council australia. Take a photograph of it and keep it on your phone you can check what to do if your asthma gets worse. This form must be completed by a medical provider to authorize administration of asthma medications. Asthma action plan provider iinstructions at iinitial ppresentation, ddetermine tthe llevel oof aasthma sseverity level of severity is determined by both impairment and risk and is assigned to the most severe category in which any feature occurs. All people with asthma should have an asthma action plan. Asthma action plan for older children childrens healthcare of atlanta. Read our tips on getting the best from a childs asthma action plan. Start quickrelief medicine albuterol at home or school to stop your asthma from getting worse. Virginia asthma action plan pdf administration of asthma medication pdf virginia asthma action plan pdf fillable form management of asthma in school setting reg 7575. Apr, 2020 everyone with asthma needs his or her own asthma action plan. Asthma action plan provider instructions at initial presentation, determine the level of asthma severity l level of severity is determined by both impairment and risk and is assigned to the most severe category in which any feature occurs.
I authorize this medication to be administered by school personnel or. It identifies personal best peak flow, levels of symptom severity, and appropriate patient action. The aap is available in many formats and languages, as well as different sized fonts and graphics. The purpose of this asthma action plan is to help families become proactive and anticipatory with respect to asthma exacerbations and their control. Connecticut department of health asthma action plans in pdf and word formats. Take the asthma control test periodically and share the results with your healthcare provider to help assess if your asthma symptoms are well controlled. Take these medicines and get help from a doctor now.
English asthma action plan directions to the provider. Our english asthma action plan has recently been updated, so the advice on the nonenglish plans isnt exactly the same, however, they are still useful for patients and clinically safe. Maine asthma prevention and control program action management plans in pdf and information to order ncr forms. This brochure provides an asthma action plan that will help you learn the steps to selfmanage your asthma so you can live a life as symptomfree as possible. Minnesota department of health asthma action plans in pdf child or adult. Exercise smoke, strong odors or spray mold colds respiratory infections chalk dustdust carpet pollen change in temperature animals dust mites tobacco smoke cockroaches. My written asthma action plan helps me judge how well i am and know what i need to do if im not. Having a personalized asthma action plan will allow you to easily identify which zone you are in and what you must do to stay in the green zone. Our english asthma action plan has recently been updated, so the advice on the non english plans isnt exactly the same, however, they are still useful for patients and clinically safe.
Health forms and regulations prince william county. My asthma action plan childrens healthcare of atlanta. This plan will be shared with school staff who care for my child. Many people with asthma are allergic to dust mites. The asthma action plan chosen should be appropriate for the persons age, treatment regimen, asthma severity, culture, language, literacy level, and ability to selfmanage. Asthma action plans aaps are written, individualized selfmanagement and educational tools that provide daily and emergency guidance to asthma patients, parents, and caregivers at home, school, and the workplace and community settings. Perform skin or blood allergy tests for all patients with persistent asthma. I request that the school assist my child with the above asthma medications and the asthma action plan as ordered by the health care provider in accordance with state laws and regulations. All of our nonenglish asthma action plans contain information standardaccredited advice and their translation has been approved by multilingual professionals. Create a personalized asthma action plan with your healthcare provider. Asthma action plan new york state department of health. This guide suggests things you can do to avoid your asthma triggers.
I consent to communication between the prescribing health care providerclinic, the school nurse, the school medical advisor. I consent to communication between the prescribing health care providerclinic, the school nurse. I give written authorization for the medications listed in the action plan to be administered in school by the nurse or other school members as appropriate. English pdf spanish pdf asthma triggers at home and in the workplace. Asthma francais french bilingual pdf health information translations peak flow meter francais french bilingual pdf. Work with your health care provider to create a plan that works for you. It contains student medication administration authorization. It is my professional opinion that heshe should be allowed to carry. Patientcentered asthma care minnesota department of health. Asthma treatment plan student parent instructions the pacnj asthma treatment plan is designed to help everyone understand the steps necessary for the individual student to achieve the goal of controlled asthma. Work with your health care provider to create a plan for your child.
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