Developed by ACAAI Date:__________________ Dear Physical Education Instructor: _____________________________________is under my care for asthma. Name of Student Because exercise is important for the child with asthma, both physically and psychologically, I am providing information and instruction concerning this child's participation in physical activities. He/she should be permitted to remain in regular P.E. classes and should be permitted to engage in regular physical activities most of the time. However, during asthma episodes (characterized by cough, wheeze, shortness of breath), activities may have to be temporarily curtailed. Each child with asthma has a different limit of tolerance to exercise. Please permit the youngster to set his/her own pace on a daily basis. In particular, children with asthma may have difficulty "running laps" and playing competitive soccer and basketball; please do not "force" the child, but let the student participate at his/her own level. Swimming is usually well-tolerated and an excellent activity for children with asthma. Warm-up exercises are often useful in warding off wheezing episodes. We do not wish the student with asthma to feel "different". Please do what is necessary toward accomplishing this end. If this student does have some problems with "endurance" sports, please permit him/her to take the following medications* before participating to prevent symptoms. Medication(s):__________________________________ In case of breathing difficulty, talk to the child reassuringly and calmly; have the child take prescribed medication.* If the treatment is ineffective or symptoms are severe, notify the school nurse or parent immediately or call 911 if appropriate. Medication(s) for acute treatment must be readily available. Medication(s):__________________________________ We welcome your help. *The student's parent has been given a "school medication request" form to transmit to the school. Where indicated, permit the child to medicate herself/himself if authorized by physician and parent. Sincerely,

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