HTML Preview Asthma Medical Management Plan page number 1.
ASTHMA MEDICAL MANAGEMENT PLAN
This plan should be completed by the student’s personal health care team and parents/guardian. It should be
reviewed with relevant school staff and copies should be kept in a place that is easily accessed by the school
nurse, trained personnel, and other authorized personnel.
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: __________________________________________________________________________
T
elephone: _______________________ Emergency Number: __________________________________
Other Emergency Contacts (Relationship):__________________________________________________
Telephone: Home _________________ Work _________________ Cell _________________________
Asthma Triggers: (circle those that apply
Animals
Insect Sting/Bee
Chalk Dust
Weather Change
Dust Mites
Exercise
Latex
Molds
Pollens
Respiratory Illness
Smoke
Strong Odors
Foods:
Other:
If Exercise: Pre-medication (dose and frequency) ___________________________________________
Exercise medifications _______________________________________________________________
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