f12

							                                                   Parent/Guardian Asthma Questionnaire                                                                     F12
                                                                Instructions


Purpose:

 The Licensed School Nurse uses the Parent/Guardian Asthma Questionnaire (PQ) to:

    To determine if the student’s asthma is under control.

    To develop an appropriate plan of care (IHP and/or Emergency Health Plan) if appropriate.

    To determine the student’s asthma severity level.

Instructions:

 The Health Service Assistant (HSA), Licensed Practical Nurse (LPN), Licensed School Nurse (LSN) will give the
  Parent/Guardian Asthma Questionnaire (PQ) to:
                                                                                                                                  th
    newly identified or newly discovered students with asthma in Pre-K through 5 Grade.

    students with asthma where more information is needed.

    students whose asthma is out of control.

 The PQ may be sent home with the student, mailed or given to the parent/guardian.

 The HSA, LPN or LSN will write in LSN name and contact information on the back of the form.

Documentation:

 Information from the PQ is summarized in the narrative notes of the Pupil Health Record.

 The form is filed in the Pupil Health Record.

 Document Severity Level on School Health Office Asthma Record (SHOAR) and computerized health problem list.

 Document that PQ was sent home on daily log.




Provided courtesy of the Healthy Learners Asthma Initiative / Minneapolis Public Schools, Health Related Services www.healthylearners.org or 612-668-0850