Ask your doctor to fill out an asthma action plan for you. It is available in english and spanish and includes a form for the authorization for use or. Strategic plan for asthma in california 2015 2019 topic. Please discuss and complete this asthma action plan aap with eligible alliance members and fax it to the alliance at 8777938504. Asthma action plan engpdf asthma and allergy foundation.
Adapted from finger lakes asthma action plan and nhlbi revised 10. This item is only available online for download and selfprinting. With the help of your doctor, use this plan to write down how to manage your asthma on a daily basis and during an attack. National heart, lung, and blood institute asthma action plan external icon. This document contains both information and form fields. Asthma management guidelines california department of. Diagnosis and management 2015, translated action plans available in chinese and punjabi, and fillable pdf. California breathing and partner organizations focus on providing access to comprehensive, culturally appropriate, patient and familycentered asthma care for people in california. Many people with asthma are allergic to the dried droppings and remains of cockroaches.
To access the various versions of the asthma action plans, please utilize the links below. Asthma state contacts and programs california ca cdc. Caring for children with asthma and allergies in child care. Handling asthma flareups is easier and less stressful when you have a plan. What actions to take when you are or your child is having symptoms of asthma or a low peak flow meter reading. Asthma management guidelines california department of education.
Here is a sample asthma action plan you can use for a child in preschool, day care, etc. Here is a sample asthma action plan you can use for students in school. Asthma treatment plan student parent instructions the pacnj asthma treatment plan is designed to help everyone understand the steps necessary for the individual student to achieve the goal of controlled asthma. This asthma action plan matches specific symptoms to actions that will help you manage your asthma.
If asthma is triggered by exercise, take d albuterol or. Asthma action plan asthma severity see reverse side asthma triggers identified things that make your asthma worse. Communication with your health care provider is an important part of using the asthma action plan. The asthma action plan provides instruction from the health professional about what to do if the child has an asthma episode. Yes no this authorization is for a maximum of one year from signature date. Feb 12, 2020 asthma is a leading cause of school absenteeism. Asthma action plan for adults american lung association. Written asthma action plans are one of the most effective asthma interventions available. Below are sample asthma action plans you can download.
For example, if you are not sure how to use your inhalers, tell your doctor. You can also talk about your action plan with a certified asthma educator or certified respiratory educator, a healthcare professional with special training in asthma. Asthma allergy self carry contract english and spanish doc is the asthma action plan working. Asthma action plan central california alliance for health.
If you have asthma, work with your healthcare provider to create a plan with instructions for early treatment of your asthma symptoms. Staff must ensure that all medications have a current expiration date or is. The plan functions as a resource for asthma interventions and activities in california and was created with the input. It is very important that you and your child follow the plan as written by your asthma health care provider. It has been developed for use by all organizations, agencies, foundations. Electronic, fillable pdf versions of asthma action plans click below to open forms. Asthma action plans also tell school and other caregivers about your childs asthma. Before taking this form to your health care provider, complete the top left section with. This asthma plan was developed by a committee facilitated by the childhood asthma initiative, a program funded by the california children and families commission, and the regional asthma management and prevention ramp initiative, a program of the public health institute. School asthma action plan for schools and families health. An action plan or asthma management plan is developed by the authorized health care provider in partnership with the student and parentguardian to assist in the management of acute asthma episodes and in maintaining longterm control. Asthma action plan name date of birth date health care provider providers phone. Providing this asthma education at the time of diagnosis and reinforcing it at all subsequent visits lead to better outcomes in terms of achieving the goals of asthma therapy, namely few symptoms, no limits on activity, rare exacerbations, and normal lung function. Links with this icon indicate that you are leaving the cdc website the centers for disease control and prevention cdc cannot attest to the accuracy of a nonfederal website.
Mild moderate severe asthma control wellcontrolled. Get to know this document, the cornerstone of personalized treatment for anyone with a food allergy. Create a personalized asthma action plan with your healthcare provider. An asthma action plan also called a management plan is a written plan that you develop with your provider to help control your asthma. The california department of public health introduces the asthma management academy asma. Overview for california schools asthma medication law. This brochure provides an asthma action plan that will help you learn the steps to selfmanage your asthma so you can live a life as symptomfree as possible. To request a supply of hard copy asthma action plans, please fill out our online form or complete the order form pdf or word and submit it via email of fax. Apr, 2020 the goal of asthma selfmanagement is to achieve better health through controlling and preventing asthma attacks. Asthma action plan national heart, lung, and blood.
Look on the back for a list of possible asthma triggers and ways to. Action plan that will help you learn the steps to selfmanage. Learn about asthma triggers, treatment options, and more. School asthma action plan for schools and families information health care provider. Symptoms are same or worse after 24 hours in the yellow zone or very short of breath or quickrelief asthma. This could include teachers, school nurses, and after school care staff. California asthma public health initiative, california department of health services. Yes o no o this authorization is for a maximum of one year from signature date. The 2012 revised dc asthma action plan fillintheblank pdf form is now available in english and spanish based on the national heart, lung, and blood institute s 2007 guidelines for the diagnosis and management of asthma. The california department of public healths cdph guidelines for the management of asthma in california schools and asthma action plan. Connect with us 1200 first street, ne, washington, dc 20002 phone.
Student may carry and selfadminister asthma medications. Many people with asthma are allergic to the dried droppings. Asthma action plans respiratory health association. Every person with asthma needs to have a personalized asthma action plan. Asthma action plans for children and adults in spanish and english. If you do not have a written asthma action plan, take the form below to your doctor and have them fill it out for you. Need help speaking with your healthcare provider about your. In january 2005 a new california law went into effect allowing students with asthma to carry and selfadminister their prescribed asthma medication. Print and take the appropriate one with you to your next health care provider visit.
My asthma action plan name date doctor doctors phone number symptoms my breathing is normal. The process of developing a written asthma action plan is important, as this should be a discussion of the persons individual asthma and its management. These tools for asthma control were created following the evidencebased guidelines. Allergens animal dander some people are allergic to the flakes of skin or dried saliva from animals with fur or feathers. Asthma action plans national asthma council australia. Asthma action plan oakland unified school district. Connecticut department of health asthma action plans in pdf and word formats. A written asthma action plan encourages selfmanagement of asthma.
I have read and signed the attached authorization form so my childs health care. It is registering now for courses in southern california. Asthma action plan national heart, lung, and blood institute. School asthma action plan for schools and families health ca. Fill, sign and download action plan template online on. Action plans are particularly helpful in preventing multiple visits to the emergency room.
Alabama alaska arizona arkansas california colorado connecticut. For more information contact the asthma society of canada at. The california department of public healths cdph guidelines for the management of asthma in california schools and asthma action plan for schools and families assist schools in effectively managing this chronic disease. Overview for california schools asthma medication law effective january 1, 2005 overview of the law in january 2005 a new california law went into effect allowing students with asthma to carry and selfadminister their prescribed asthma medication. An asthma action plan allows you and your healthcare provider to create a. Work with your health care provider to create a plan for your child. A list of the persons triggers and how to avoid them, instructions for taking asthma medicine, information on what to do during an asthma episode, instructions on when to call a doctor, and. Guidelines for the management of asthma in california schools. All people with asthma should have an asthma action plan. Take the asthma control test periodically and share the results with your healthcare provider to help assess if your asthma symptoms are well controlled. The form identifies known triggers, what medications to use, when and how to use them, and when to contact the health care provider or.
Symptoms are same or worse after 24 hours in the yellow zone or very short of breath or quickrelief asthma medicines have not helped or cannot do usual activities work, play peak flow meter if used. To download straight to your computer, right click and choose save target as. Exiting cde pdf management of asthma if student does not have an action plan exiting cde pdf asthma episode when a nurse is not available exiting cde pdf. The plan functions as a resource for asthma interventions and activities in california.
School asthma action plan for schools and families information health ca re p ovider information green zone personal best peak flow pf date. School asthma action plan for schools and families information health care provider information green zone personal best peak flow pf date. Work with your doctor to make an asthma action plan what is a pdf document. If you would like more information on illinois asthma program, please contact the illinois department of public health at 2177823300. The colors of a traffic light will help you use your asthma. Asma teaches community and layhealth workers how to provide national guidelinesbased care and education to californians living with asthma. National and statewide ca asthma resources for healthcare providers.
This asthma action plan is adapted from the asthma action plan created by the national institutes of health. The asthma action plan explains the specific care the child or staff member may need. Electronic, fillable pdf versions of asthma action plans. Create an asthma action plan american lung association. Asthma is getting worse cough, wheeze, chest tightness, or shortness of breath, or waking at night due to asthma, or can do some, but not all, usual activitiesorpeak flow.
The guidelines recommend that all children and adults with asthma have a written asthma action plan. Asthma action plan for children age 618 child health bc. Asthma and allergy foundation of america 1235 south clark street suite 305, arlington, va 22202 phone. Please discuss and complete this asthma action plan aap with eligible alliance members and fax it to the alliance at 877793. To read information, use the down arrow from a form field. Look on the back for a list of possible asthma triggers and ways to avoid them. Illinois department of public health asthma action plan. This legislation amended the california education code so that students with asthma would have immediate access to their potentially lifesaving medications.
Signs of an asthma episode or asthma attack when to seek emergency care. To request a supply of hard copy asthma action plans, please fill out our online form or complete the order form pdf. Instructions for appropriate use of asthma medications. Updated march 2011 required healthcare provider signature. Student is able to selfadminister asthma medications. Open these forms online and fill in all the required information before you.
This asthma action plan for schools and families was developed by the california asthma public health initiative, california department of health services. Fillable form 2014 healthy breathing for life asthma action plan provider. An action plan or asthma management plan is developed by the authorized health care provider in partnership with the student and parentguardian to assist in the management of acute asthma. Print and take this sample action plan with you to your next appointment to start a. Asthma action plan for schools and families health care.
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