PARENT LETTER: ALLERGY/ASTHMA
(Return this form to the Health Office at your
child’s school as soon as possible.)
Date: ______School/Grade:______
Dear Parent/Guardian:
Our records indicate that ______Student Number ______has allergies and/or asthma. If your child has allergies please complete Section A. If your child has asthma please complete Section B. If your child has both allergies and asthma, please complete Sections A & B. Thank you!
______
School Nurse/Phone Number
Section A Allergies
1.My child is allergic to (e.g., dust, bees, animal dander, etc.) ______
______
2.His/her most recent episode of allergy trouble was ______
______
3.When my child suffers from his/her allergies he/she exhibits the following symptoms (e.g., runny nose, itchy eyes, etc.)
______
4.Are your child's allergies worse at any particular time of the year? ______
If yes, when? ______
- Does your child take medication for his/her allergies? _____ If yes, please provide name, dosage, times taken, and any side effects observed for medicine taken at home or school.
______
______
6.Name of health care provider supervising treatment: ______
Phone______
7.Do your child's allergies restrict his/her activities in any way? Yes _____ No _____
If yes, how? ______
8.IF your child is allergic to insects (bees, wasps, etc.) please read and complete: If your child is stung at school, health office staff will 1) observe closely, 2) give medication if ordered by health care provider, 3) contact Rescue Squad if indicated, 4) notify parent. Please indicate if you prefer a different course of action.
______
-over-
Section B Asthma
- Circle the triggers for your child's asthma: Change in weather; allergies; exercise; viral infection. List others:
______
2.Describe your child’s asthma symptoms and how often they occur.
______
3.Describe any activity restrictions. A note from your child’s health care provider is required for gym or recess limitations.
______
- Health care provider treating your child's asthma: ______
Phone ______
5.Please list any medications your child takes.
Medication Name Dose How oftenTaken Daily orwhen needed
______
______
______
6.Does your child understand asthma and how to manage it? Yes _____ No _____
7.Does your child use a peak flow meter to assess asthmatic symptoms? Yes _____ No _____
If yes, what are the ranges that indicate mild, moderate, or severe symptoms?
Mild ______Moderate ______Severe ______
8.If your child should have an asthma attack in school, health office staff will 1) encourage easy breathing and relaxation, 2) give medication if ordered by health care provider, 3) observe closely and contact parents or rescue squad if indicated. Please indicate if you prefer a different course of action. ______
9.Will your child carry his/her own inhaler? Yes _____ No _____
If yes, complete “Contract for Self-Administration of Inhaler.” (Form 101015)
10.May this information be shared with appropriate school personnel, as determined by the school nurse? Yes ______No ______
11.May this information be included on a health concern list that is maintained in the school health office? Yes _____ No _____
______
Signature of Parent/Legal Guardian Date
Home Phone:______Work Phone:______