School District Letterhead Here
School: ______
Date:
Dear: ______
Primary Care Provider Name
I am writing regarding your patient, D.O.B. .
The following is provided for your information as an adjunct to care:
r Missed _____ days of school as of ______possibly due to asthma.
r Is using asthma rescue medication for symptoms occurring more than 2 times per week at school.
r Is not able to fully participate in PE classes or athletics based on reports/self-reported symptoms possibly related to asthma.
r Has had ____visits to the school health office for symptoms related to asthma.
r Has required emergency asthma management @ school on ______. 911 or ER referral on______
r Asthma Control Test (ACT) scores have been below 19 at each of the visits to the school health office. The school health records suggest that this student’s asthma may not be well controlled based on the new National Asthma Education and Prevention Program (NAEPP epr-3) guidelines. The new NAEPP epr-3 guidelines and an Asthma Control Test are attached for your convenience
The family has agreed to follow-up with you
r Please consider completing an “Asthma Action Plan” form with your prescribed asthma management plan to guide the care for the student, a plan can be downloaded from http://www.ct.gov/dph/asthma
r The Medication Administration Authorization and The Parent Consent to Exchange Health Information forms are also attached. Would you please ask the parent to sign these at the time of the visit so that we can assist you with your asthma education and management program for your patient and the family. Authorization form can be downloaded from http://www.sde.ct.gov/sde/lib/sde/PDF/deps/student/health/MedicationForm.pdf
r Student does not have a rescue bronchodilator medicine and Medicine Administration Authorization for school use. Please consider prescribing a rescue bronchodilator with a spacer for PRN use or in unit dose with extra tubing for administration by nebulizer.
Please do not hesitate to call if there are any questions or concerns. Thank you!
Sincerely,
School nurse signature
Phone: ( ) ______
Print school nurse name
*****Completed Asthma Action Plans, Medicine Administration Authorization, and, Health Assessment Record forms may be faxed to: ( ) ______
This form may be duplicated or changed to suit your needs and your patients’ or student’s needs.