Physician Treatment Plan for
Self-Administration of  
Anaphylaxis or Asthma Medication
Physician to Complete

Student: ________________________________ Birthdate: ________   School: ______________  

Physician Diagnosis: _____________________________________________________________

Medication                                Purpose                             Dosage & Time       How Soon Repeated

(to be self administered)                                                                                         (regularly administered)

_____________________       __________________________________           _________________        _______________________

________________      _________________________        _____________     __________________

________________      _________________________        _____________     __________________

Special Circumstances for use: _______________________________________________________ ________________________________________________________________________________________________
Other medications: _______________________________________________________________
(NOT self administered)

_______________________________________________________________________________________________________________________
Asthma Peak Flow Information :

Green Zone is _______ to   ________
(Breathing action is good)
Yellow Zone is ______   to ________     Treatment Action _________________________________________________

 (Caution)                     ________________________________________________________________

Red Zone is ________                                Treatment Action_________________________________________________

                (ALERT)                                        _______________________________________________________________

Skills Necessary for Responsible Self Administration of Medication:

1.   Student is capable of identifying individual medication and medication is properly labeled.	Yes	No
2.   Student is able to identify specific symptoms and purpose of this prescribed medication.	Yes	No
3.   Student is knowledgeable of medication dosage and method of medication administration.	Yes	No
4.   Student is knowledgeable of how to access assistance for self in an emergency.	Yes	No
5.   Student is capable of self –administering the prescribed medication.	Yes	No
6.   Student will carry medication in a responsible manner.	Yes	No
7.   Student will not share medications with other students.   Any abuse of self-administered    medications or this plan will result in the loss of this privilege.	Yes	No

 The above student has demonstrated the skills necessary for responsible self administration of medication             Yes________              No________

This treatment plan expires at the end of each school year unless an earlier date is noted here: _________

 ____________________________       ____________________________   _________________

Health Care Provider Signature                                                                           Physician (Printed Name)                                                   Today’s Date

 

                                                                                                                                                                                                             2-2006

OVER - PARENT AUTHORIZATION