Asthma Emergency Action PlanChild's Name(Required)Age(Required)Child's Full Name(Required)Date Of Birth(Required) MM slash DD slash YYYY Child's Photo(Required)Max. file size: 512 MB.Parent/Guardian Name(Required) First Last Home Phone(Required)Work Phone(Required)Emergency Contact Name(Required) First Last Home Phone(Required)Work Phone(Required)Doctor Name(Required)Phone(Required)What are the symptoms(Required)Medicine(Required)How Much(Required)How(Required)When to contact parentOther InstructionIt is parent responsibility to notify the facility of any change in the child's conditionDanger Zone1) Medicine is not helping2) Breathing is hard & fast3) Trouble SpeakingCall doctor, if cannot contact take child to emergency 911 inform parentSign belowPrimary Care Provider(Required)Date(Required) MM slash DD slash YYYY Parent/Guardian(Required)Date(Required) MM slash DD slash YYYY
