Asthma Care Plan 23/24

Form from: St Michael and All Angels

print to class print to medical folder pdf saved to asthma file

Our Asthma Policy can be read here St Michaels Asthma policy

All our documents are available on paper free of charge, please enquire at the school office.

Child's Name

Child's Year Group

Date of birth

Allergies

Emergency Contact

Emergency contact's daytime telephone number

Doctor's phone number

What are the signs that you/your child may be having an attack?

Are there any key words you/your child may use to express their asthma symptoms?

What is the name of your/your child's reliever medicine and device?

Do you/your child need help taking their inhaler?

Yes No

What are your/your child's known asthma triggers?

Do you/your child need to take their reliever before exercise?

Yes No

If YES, Warm up properly and take 2 puffs (1 at a time) of the reliever inhaler 15 minutes before any exercise unless otherwise indicated below:

I give my consent for school staff to administer/assist my child with their own reliever inhaler as required. Their inhaler is clearly labelled and in date.

signature _{please use your mouse or finger sign above}

Name of person completing form

Relationship to child

Consent to use of emergency Salbutamol Inhaler

Child showing symptoms of asthma/having asthma attack

I confirm that my child has

been diagnosed with asthma been prescribed an inhaler _{choose all that apply}

I confirm that my child has an in date, working inhaler that will be kept in school

Name of person completing consent form

Your relationship to this child

Parent/carers address

Parent/carers telephone

Parent/carers email

In the event of my child displaying symptoms of asthma, and if their inhaler is not available or is unusable, I consent for my child to receive Salbutamol from an emergency inhaler held by the school for such emergencies

signature _{please use your mouse or finger sign above}