Get the free Asthma Action Plan/Medication Authorization Form - cms k12 nc

Asthma Action Plan/Medication Authorization Form For all children with asthma Mecklenburg County Health Dept. Student Name CMS Student ID# School/Year Grade/Teacher Parent/Guardian Contact Number

How to fill out asthma action planmedication authorization

How to fill out asthma action plan/medication authorization

1. Start by obtaining the necessary form: Contact your healthcare provider or the organization responsible for managing your asthma care to request an asthma action plan/medication authorization form. They will provide you with the appropriate document.
2. Read the instructions: Carefully review the instructions provided on the form. Understand the purpose of the form and what information needs to be filled out.
3. Personal information: Begin by filling out your personal information. This typically includes your full name, date of birth, contact information, and any relevant identification numbers.
4. Medical history: Provide details about your medical history, including any pre-existing conditions, allergies, and previous asthma-related hospitalizations or emergencies. This information helps healthcare professionals understand your health background.
5. Current medications: List all the medications you are currently taking for your asthma. Include the names, dosages, and frequency of use. This helps healthcare providers monitor your medication regimen and make any necessary adjustments.
6. Emergency contacts: Write down the names and contact information of individuals who should be notified in case of an asthma-related emergency. These emergency contacts could be family members, close friends, or healthcare professionals.
7. Asthma action plan: This section requires the most attention. Follow the instructions provided to complete your asthma action plan. This plan outlines specific steps to take depending on asthma symptoms and severity levels. It may include instructions for medication use, peak flow measurements, or emergency procedures. Fill out each section accurately and clearly to ensure the plan can be easily understood in times of need.
8. Healthcare provider information: Include the name, contact information, and any important details of your primary healthcare provider or asthma specialist. This allows other healthcare professionals, such as emergency responders, to communicate and collaborate effectively regarding your condition.

Who needs asthma action plan/medication authorization?

1. Individuals with asthma: Anyone who has been diagnosed with asthma should have an asthma action plan/medication authorization. This plan helps guide them in managing their condition, ensuring they have the appropriate medications and know how to handle various asthma-related situations.
2. Parents or caregivers of children with asthma: If you are responsible for a child with asthma, it is crucial to have an asthma action plan/medication authorization. This enables you to understand their treatment plan and take appropriate actions during emergencies, even if the child is unable to communicate their needs effectively.
3. Schools, daycares, and other care facilities: Institutions responsible for the well-being of individuals with asthma, such as schools and daycares, often require asthma action plans/medication authorizations from students or patients. These documents ensure that the facility is aware of the individual's condition and can provide appropriate assistance if needed.

Remember, asthma action plans/medication authorizations should be regularly reviewed and updated in consultation with your healthcare provider to ensure they reflect your current condition and treatment needs.

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What is asthma action plan/medication authorization?

Asthma action plan/medication authorization is a document that outlines the medications and instructions for managing asthma symptoms.

Who is required to file asthma action plan/medication authorization?

Parents or guardians of students with asthma are required to file asthma action plan/medication authorization with the school.

How to fill out asthma action plan/medication authorization?

Asthma action plan/medication authorization can be filled out by a healthcare provider with the necessary information about the student's asthma condition and medication needs.

What is the purpose of asthma action plan/medication authorization?

The purpose of asthma action plan/medication authorization is to ensure that the school is aware of the student's medical needs and can provide appropriate care in case of an asthma attack.

What information must be reported on asthma action plan/medication authorization?

Asthma action plan/medication authorization must include information about the student's medications, dosage, frequency, and emergency contact information.