Asthma record card

CHILDREN’S SERVICES ASTHMA ACTION PLAN
(To be updated at least annually and as needed)
For children in childcare,
kindergarten, preschool, family day
care and out of school hours care
Instructions
To be completed by parents/guardians in consultation with their child’s doctor. Parents/guardians should inform the children’s services that their child attends immediately if there are any changes to this record. Please tick the appropriate boxes or print your responses in the blank spaces where indicated. The information on this Plan is confidential. All staff that care for your child will have access to this information. It will only be distributed to them to provide safe asthma management for your child. The service will only disclose this information to others after they have obtained your consent if it is to be used elsewhere. Child’s name: …………………….…. ………………………… Sex: M F PERSONAL DETAILS
Parent/Guardian’s Name: …………………………………………….………………………. Telephone: (H) ………………………. (W) …………………… (M) …………………………. Emergency contact person:………………………………………………………………….… Relationship (eg, parent/guardian/grandparent): ……………………………………………. Emergency contact telephone: (H) ………………………. (W) ……………………………. (M) ……………………….……………………….………. Doctor: ……………………………………. Telephone: …………………………………… Ambulance member: Yes No Membership number: ………………….………. USUAL ASTHMA ACTION PLAN
Usual signs of child’s asthma
Signs of child’s asthma worsening
What triggers the child’s asthma?
……………………………………. ……………………………………. Does the child communicate when they experience symptoms and/or need medication? Yes No
Does the child take any asthma medication before exercise/play?
MEDICATION REQUIREMENTS USUALLY TAKEN IN CARE
(Include relievers, preventers, symptom controllers and combination medication before exercise).
Name of Medication
When and how much?
(e.g. Ventolin, Flixotide)
(e.g. puffer & spacer)
(e.g. one puff morning and night)
The Asthma Foundation of Victoria April 2012 ASTHMA FIRST AID PLAN
Please tick your preferred Asthma First Aid Plan NATIONALLY RECOMMENDED ASTHMA FIRST AID PLAN
Step 1. Sit the person upright
Give medication
-
Use a spacer and face mask if you have one, (use the puffer alone if a spacer and face mask are not available) The person is to take 4 breaths from the spacer after each puff
Giving blue reliever medication to someone who doesn’t have asthma is unlikely to harm them Step 3. Wait 4 minutes
If there is no improvement, repeat step 2.
Step 4 If there is still no improvement call emergency assistance (DIAL 000).
Tell the operator the person is having an asthma attack Keep giving 4 puffs, 4 breaths per puff, every 4 minutes while you wait for emergency assistance
Call emergency assistance immediately (DIAL 000) if the person’s asthma suddenly becomes
worse
CHILD’S ASTHMA FIRST AID PLAN (approved by doctor) (if different from above)
If the child’s condition suddenly deteriorates or if at any time you are concerned — call an
ambulance immediately (000).
In the event of an asthma attack, I agree to my child receiving the treatment described above. I authorise children’s services staff to assist my child with taking asthma medication should he/she require help. I will notify you in writing if there are any changes to these instructions. I agree to pay all expenses incurred for any medical treatment deemed necessary. Please notify me if my child has received asthma first aid. Parent’s/Guardian’s Signature: ________________________________ Date: _____/_____/_____ Doctor’s Signature: __________________________________________ Date: _____/_____/_____ For further information about asthma management, please contact The Asthma Foundation of Victoria on (03) 9326 7088,
toll free 1800 645 130, or visi
The Asthma Foundation of Victoria April 2012

Source: http://www.sunnysidekindergarten.org.au/wp-content/uploads/2013/11/Asthma-Management-Form.pdf