Asthma Action Plan
Name of Parent/Carer filling out this form
*
First Name
Last Name
Name of Child
*
First Name
Last Name
What are your child’s triggers ( things that make their Asthma worse )
*
What signs indicate that your child is having an attack?
*
Reliver treatment to be taken when needed? (Please detail name and dose of medication)
*
Does your child tell you when they need reliever treatment?
*
Yes
No
Does your child need help taking their reliver medication?
*
Yes
No
Does your child need to take any medication before exercise or play?
*
Yes
No
Does your child need to take any other Asthma medications whilst in school?
*
Yes
No
Please ensure that your child always carries their inhaler on them.
Submit
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