Developed by ACAAI Date:__________________ Dear School Nurse and Classroom Instructor: _____________________________________is under my care for asthma. Name of Student All of us—physicians, parents, and school personnel—want to do everything possible to provide a normal learning experience for this student. The following information and instructions are provided so that we may work together to meet this goal. Permit the student to remain in regular physical education classes. We encourage patients with asthma to decide their activity level on a day-to-day basis. If you feel inappropriate choices are being made, please contact me so that we can all help the student maintain as normal an activity level as possible. If the student begins to miss a great deal of school because of asthma or allergies, urge the parents to notify me. If this student is not performing well in school, is drowsy, irritable, lethargic, lacks endurance or has headaches or nausea, please have the parents notify me. These problems may be due to his/her medical condition or to side effects of asthma or allergy medication. Once we know the problems, changes can be made. If medications are required for use in school, they will be listed on a separate form. Please permit the student to self-medicate when authorized by me and the parent and to have medication for acute treatment readily available at all times. We welcome your help. Sincerely,

_________________________ (Physician's Signature) _________________________ Address _________________________ City, State, ZIP _________________________ Telephone _________________________ (Parent's Signature) _________________________ Address _________________________ City, State, ZIP _________________________ Telephone