COLLEGE PLACE PUBLIC SCHOOLS 1755 S. College Avenue College Place, WA 99324
Health Services
509.525.4827 Fax 509.525.3741 Cpps.org
ASTHMA INFORMATION FORM Student’s Name:________________________________ School:__________________ Grade:______ Teacher:__________________ Parent/Guardian:____________________________ Telephone (home):_____________ (cell):_____________(work):_____________ The following information is helpful to the nurse and school staff in determining any special needs for your child. Please answer the questions to the best of your ability. If you desire a conference with the school nurse, please call for an appointment. Thank you for your assistance. 1.
How long has your child had asthma? __________________years ________________months
2.
How many days would you estimate he/she missed school last year due to asthma?____________
3.
How many times in the past year has your child been: a)
hospitalized overnight or longer for asthma? (check one) ____none ____one ____two-four ____more than four
b)
treated in an emergency room? (check one) ____none ____one ____two-four ____more than four
c)
treated in a Doctor’s office for non-routine asthma? (check one) ____none ____one ____two-four ____more than four
4.
What triggers your child’s asthma episodes? (check all that apply) ____respiratory infections ____emotions ____chemical odors ____foods ____weather changes
Please check all special considerations related to your child’s asthma that he/she will need while at school ____none ____avoiding strong smelling chemicals or irritants such as chalk dust, saw dust or paint ____modified recess or gym class (Note from physician required) ____special considerations while on field trips ____special transportation to and from school (Note from physician recommended. School district may require additional information and planning.) ____avoiding animals/pets ____Other_________________________________________________________________
CPPS.ORG College Place Public School District is an equal opportunity employer and complies with all requirements of the ADA.
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COLLEGE PLACE PUBLIC SCHOOLS 1755 S. College Avenue College Place, WA 99324
Health Services
509.525.4827 Fax 509.525.3741 Cpps.org
6.
What are your child’s early warning signs of an asthma episode? (check all that apply) ____cough
If your child’s asthma is monitored with a peak flow meter, write in his/her best peak flow rate _______________________
8. List all medications your child takes for asthma. Please include routine and non-routine (as needed) medicines. Indicate if using metered dose inhaler (puffer), spacer/chamber, nebulizer, or pills. (A signed Authorization for Medication to be Taken at School form for each medication must be provided if medications are required during school hours.)
Medication taken as needed
Amount
How taken
Time given
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Medication taken on a regular schedule
9.
What, if any, side effects does your child have from his/her medication? _______________________________________________________________________________
10.
Name of child’s doctor (for asthma):_________________________________________________ Address: _____________________________________________ Phone: ____________________
11.
Do we have your permission to call your child’s doctor for more information about your child’s asthma in the case of an emergency if we cannot contact you? ______Yes ______No
12.
If your child has a severe asthma episode and emergency services (e.g. 911) are called, what is your choice of hospital for treatment? Note: Hospital choice may not be an option at time of emergency.
_________________________________________ ______________________________________________ Hospital Name Address ************************************************************************************************************ ___________________________________________________________________ Parent/guardian signature
______________ Date
***Please return this form to school as soon as possible***
CPPS.ORG College Place Public School District is an equal opportunity employer and complies with all requirements of the ADA.
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COLLEGE PLACE PUBLIC SCHOOLS 1755 S. College Avenue College Place, WA 99324
Health Services
509.525.4827 Fax 509.525.3741 Cpps.org
INFORMACION SOBRE EL ASMA Nombre del estudiante:________________________________ Escuela:________________ Grado:_____ Maestra:_______________ Parent/Guardián:____________________________Teléfono (casa):____________ (celular)_____________ (trabajo):____________ La información a continuación es necesaria para la enfermera de la escuela y el personal de la oficina en caso de necesidad para su hijo/a. por favor responda a las preguntas lo mejor que pueda. Si usted desea tener una conferencia con la enfermera de la escuela, por favor llame para hacer una cita. Gracias por su ayuda. 1.
¿Cuanto hace que su hijo tiene asma? __________________Años ________________meses
2.
¿Cuantos días de escuela cree usted que su hijo perdió el año pasado por esta causa?_______
3.
¿Cuantas veces el año pasado su hijo ha sido: a)
¿Hospitalizado en la noche por esta causa? (marque uno) ____Ninguno ____uno ____dos a cuatro ____mas de cuatro
b)
¿Llevado a emergencia? (marque uno) ____none ____one ____two-four ____more than four
c)
¿Tratado en la oficina del doctor por causas no de rutina? (marque uno) ____ninguno ____una ____dos-cuatro ____mas de cuatro
4.
Que le propicia un ataque de asma a su hijo? (marque todo lo que aplica) ____infecciones respiratorias ____emociones ____olores químicos ____comidas ____cambios de clima
Por favor explique todas las consideraciones relacionadas con el asma que su hijo necesita tener mientras esta en la escuela ____ninguna ____evitar los olores fuertes de químicos o irritantes como tiza, polvo o pintura ____modificar el recreo o la clase de PE* Nota requerida Del doctor ____consideraciones especiales en los viajes ____consideraciones especiales en la transportación de la escuela (Nota recomendada Del doctor. El distrito escolar tal vez necesite más información.) ____evitar contacto con animales ____otros_________________________________________________________________
CPPS.ORG College Place Public School District is an equal opportunity employer and complies with all requirements of the ADA.
Page 1 of 2
COLLEGE PLACE PUBLIC SCHOOLS 1755 S. College Avenue College Place, WA 99324
Health Services
509.525.4827 Fax 509.525.3741 Cpps.org
6.
¿Cuales son los síntomas tempranos de su hijo cuando tiene un ataque de asma? (marque uno) ____tos
Si el asma de su hijo es medida con el tes de respiración, escriba cuales han sido las medidas mas frecuentes ____________________
8.
Escriba todas las medicinas que su hijo toma para el asma. Por favor incluya las medicinas de rutina y las que no lo son ( según sea necesario) Indique las dosis que debe tomar y la frecuencia del uso del inhalador, pastillas, u otro requerimiento medico (una forma firmada (autorización para que la medicina sea tomada en la escuela) para cada medicina debe ser proporcionada si los medicinas se requieren durante horas de la escuela.) Medicinas*no de rutina (cuando las necesita) *
cantidad
como se toma
frecuencia
______________________________________
_________
_________
_________
______________________________________
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_________
_________
______________________________________
_________
_________
_________
______________________________________
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______________________________________
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Medicinas tomadas de rutina
9.
¿Cuáles si es que tiene algún efecto secundario tiene su hijo cuando toma estas medicinas? _______________________________________________________________________________
10.
Nombre del doctor de su hijo (para el asma):__________________________________________ Dirección: ___________________________________________Teléfono: _________________
11.
¿Tenemos permiso de llamar al doctor de su hijo por el asma si es que no podemos ponernos en contacto con usted y necesitamos mas información? ______Si ______No
12.
Si su hijo tiene una emergencia y tenemos que llamar al 911, cual es el hospital de preferencia para que le d en tratamiento. Nota: la opción de hospital puede no ser la señalada en caso de tiempo necesario en la emergencia. ______________________________________________________ Nombre del Hospital
************************************************************************************************************************ ______________________________________________________ Firma del padre o guardián
__________________ Fecha
***Vuelva por favor esta forma a la escuela cuanto antes***
CPPS.ORG College Place Public School District is an equal opportunity employer and complies with all requirements of the ADA.
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