Form from: Alwoodley Primary

Child's name

Date of birth

Address

Parent/Carer name

Telephone - home

Telephone - work

Telephone - mobile

Parent/Carer responsibility - Please ensure all medication is in date, review the form at least once a year and also notify your child's school if their treatment or contacts change during the year.


Reliever treatment when needed

For wheeze, cough, shortness of breath or sudden tightness in the chest, give/allow my child to take the medicines below.  After treatment and as soon as they feel better they can return to normal activity.

Medical Condition

Type of Medicine eg Salbutamol

Can your child administer this alone

Expiry date

What are your child's triggers? (things that make their asthma worse)

What signs can indicate that your child is having an asthma attack?

Any Additional Information

What to do in an asthma attack

1. Make sure the child takes 1 or 2 puffs of their reliever inhaler (usually blue) preferably through a spacer.

2. Sit the child up and encourage them to take slow steady breaths.

3. If no immediate improvement, make sure the child takes 2 puffs of reliever inhaler (1 puff at a time) every 2 minutes. They can take up to 10 puffs.

4. If the child does not feel any better after taking their inhaler as above, call 999 for an ambulance. If an ambulance does not arrive within 10 minutes repeat step 3.

5. I give permission for a school inhaler to be used in an emergency.

Please sign below

signatureplease use your mouse or finger sign above

Date:

Your name

Your email