ASTHMA STATUS
                                               (To be completed by parent/guardian)

Student:                                            Today’s Date:                           Grade:

Date of Birth:                                      Age at diagnosis of asthma:             Hospitalized? (Date)
                                                                                            ER? (Date )
Parent/guardian completing this form and email address:

Medications: Please list all your child’s medications.
   1.                                                                  2.
   3.                                                                  4.

Asthma Control: What is your child’s current level of control with medication? (If coughing wakes you or your child up
more than two nights in a month or your child is using a rescue inhaler more than twice a week during the day, your child’s
asthma may not be well controlled and you should have a conversation with your child’s doctor. This does not apply if your
child uses an inhaler for exercise induced asthma only.) Click on or X all that apply.
    Well controlled with few to no symptoms.
   Moderately controlled. (Explain symptoms/frequency)

   Not well controlled. (Explain symptoms/frequency)

Season typically affected? Click on or X on all that apply
  Fall                           Winter                              Spring                          Summer

Triggers (Things that can start asthma symptoms) Click on or X all that apply.
   Irritants (Smoke, fumes,         Allergens (pollens, dust,    Respiratory disorders               Dietary Substances
perfumes, cleaning products, dust mites, mold, animal         (viral infections such as a         (Foods, additives,
cooking oils)                    dander, roaches)             cold , sinusitis, rhinitis)         preservatives)
   Medicines (Aspirin and           Emotional stress             Air quality (Cold, dry,             Weather changes
other non-steroidal anti-        (Laughing, crying, anger,    hot, humid)
inflammatory agents)             fear)
   Exercise                                                      Other:

Usual Signs and Symptoms that indicate an asthma episode requiring medication: Click on or X all that apply
  Constant/frequent cough     Difficulty breathing/short        Tight chest/chest pain      Breathing faster than
                           of breath                                                     usual
  Wheezing                    Tires easily, especially with exercise       Other: (list)

What should your child do to prevent an asthma episode? Click on or X all that apply
 Cover nose and mouth in cold weather.                       Use inhaler before exercise.
 Avoid contact with animals.                                 Avoid known allergens (list)
 Other: (List)

What does your child do to relieve symptoms during an asthma episode? Click on or X all that apply
 Loosen clothing                         Relaxation exercises                   Abdominal (belly) breathing
 Sips warm fluids                        Pursed Lip Breathing                   Uses Inhaler

Student Knowledge: Click on or X yes or no.
Does your child know when he/she is having an asthma episode that requires medication?            Yes               No
Does your child know what to tell an adult when he/she is having an asthma episode?               Yes               No

Please click on or X the box or boxes which best describe where your child’s inhaler will be kept. (Best practice is to have
one inhaler in the health office and one with the child.)

   Health office              Classroom                  Locker                       Backpack             Gym Locker

Code: Asthma History Updated May 2011                             Please complete Page 2 or the back of this form

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