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Name: DOB Teacher: Grade: Allergy to: Asthma: Yes: No: (higher risk for a severe reaction)MEDICATIONS/DOSES: EPINEPHRINE AUTOINJECTOR: (BRAND AND DOSE): JR Audio JR BRONCHODILATOR: (BRAND AND DOSE):
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What is Asthma:Yes:No: (higher risk for a severe reaction) Form?

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Asthmayesno is higher risk for individuals with asthma.
Healthcare providers and insurance companies are required to file asthmayesno for individuals at higher risk.
You can fill out asthmayesno higher risk form online or by contacting your healthcare provider.
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