To obtain an asthma history based on symptoms both at home and school as well as an opportunity for the physician to receive the school contact information for their files.
Patients with asthma, and their parents/guardians
Filled out at office visit with doctor to document asthma symptoms, and help classify severity level
To provide the patient, parent, and school info about a child?s medication program, and guidance as to what to do for when the child?s asthma worsens. This form is in black and white so it is easily copied in the physician office.
Doctors, School Nurses, Parents, Patients
Completed by the doctor and sent to school via fax or parent.
To help facilitate communication between school nurses or personnel and the student?s own health care provider. It meets both HIPAA and FERPA requirements for the use or disclosure of health information.
Doctors, School Personnel
Given to the parent for signature at the doctor office visit or by a member of the school faculty to allow for seamless communication with the school and school nurse.
To help facilitate a thorough asthma history that includes specific school information. This form is part of the patient?s chart within the doctor?s office.
Physicians
Used in patients charts to collect information. This form included specific school health questions.
