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Child Details

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Last Name*

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Asthma Plan

An Asthma Plan must be in place for every child with who suffers from Asthma. Asthma is a chronic lung disease. It is caused by inflammation and muscle tightening around the airways, which makes it harder to breathe. Please complete the below action plan for the relevant child below. If you have a specific action plan created by your doctor, please ensure you upload a copy with this form, so we can provide a copy your Educator.

Triggers*

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Symptoms/what to look out for*

For example, chest tightness, pain, or shortness of breath.

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List of child's usual medicines (Relievers or Preventers)*

Please include name of medicines, doses, when to take each dose.

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Instructions on what the Educator should do if your child's asthma is getting worse*

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Signs of worsening asthma and what to do if the Educator sees these signs*

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When to give more reliever medicine*

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What to do in an asthma emergency (if the child does not respond to initial treatment)*

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Please upload any supporting evidence or documentation here*

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By submitting this form you confirm that the above plan accurately reflects that of the child’s treating practitioners and that you will update as per policy guidelines.

Asthma Plan

Client Details

Child Details

Asthma Plan

By submitting this form you confirm that the above plan accurately reflects that of the child’s treating practitioners and that you will update as per policy guidelines.

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