Jamul-Dulzura Union School District
Health Office
14344 Olive Vista Drive Jamul, California 91935
Office Telephone (619) 669-2751

Fax (619) 669-7632
From the Health Office
Dear JDUSD Parent/Guardian:
It is our desire to provide an optimum environment for the health, well-being, and safety of all our students.
Good management of your child’s asthma is important to his or her success at school. Clear communication
between you and your child, your health care provider and school staff is the key to managing asthma at school.
A written Asthma Action Plan developed by your health care provider and shared with the school will help keep
your child safe at school. Following the Asthma Action Plan will enable your child to participate fully in school
activities.
Please talk with your health care provider about completing the attached forms. Forms can be faxed directly to
my fax number at (619) 669-7632.
The school will need the following:
Parent Health Questionnaire
Asthma Action Plan
Authorization of Medication Administration
Medication in prescription container
An adult must deliver medication in its prescription container to the school.
Please feel free to contact me regarding any school health-related matters.
Best Regards,
District Nurse
Jamul-Dulzura Union School District
Parent/Guardian Asthma Questionnaire
Jamul-Dulzura Union School District
It has come to our attention that your child has asthma or breathing problems. The school nurse needs more information
on your child’s asthma or breathing problems. This will help us take care of your child at school. Please complete
both sides of this form.
Child’s Name ___________________________________________________ Grade ________ Date ______________
Parent/Guardian _________________________________ Home Phone Number (______)________________________
Work Number (_____)_____________________________ Cell Phone Number (______)_________________________
Where does your child receive his/her asthma care: (Name of clinic)
__________________________________________________________________
Name of Healthcare Provider ____________________________ Clinic Phone # ________________________
Would you like information on free / low cost insurance? Yes
No
1.
Please circle if your child’s asthma is severe or not severe or anywhere in between (circle #) :
Not Severe 1
2
3
4 5 Severe
2.
How many days did your child miss school last year due to his/her asthma?
0 days
1 – 2 days
3-5 days
6-9 days
10-14 days
15 or more days
3.
How many times has your child been hospitalized overnight or longer for asthma in the past 12 months?
0 times
1 time
2 times
3 times
4 times
5 or more times
4.
How many times has your child been treated in the Emergency Department for asthma in the past 12 months?
0 times
1 time
2 times
3 times
4 times
5 or more times
5.
What triggers your child’s asthma or makes it worse?
Smoke
Chalk / chalk dust
Animals / pets
Strong smells / perfume
Dust / dust mites
Foods (which ones:____________________________________)
Cockroaches
Having a cold / respiratory illness
Grass / flowers
Stress or emotional upsets
Mold
Changes in weather / very cold or hot air
Exercise, sports, or playing hard
6.
Does anybody in the household smoke?
7.
For each season of the year, to what extent does your child usually have asthma symptoms? (Mark an X for each season below)
A lot
A little
None
Fall
Winter
Spring
Summer
8.
In the past month, during the day, how often has your child had a hard time with coughing, wheezing or breathing?
2 times a week or less
9.
Yes
More than 2 times a week
No
Every day (at least once every day)
Constantly (all of the time every day)
In the past month, during the night, how often does your child wake up or have a hard time with coughing, wheezing or
breathing?
2 times a month or less
More than 2 times a month
10. Does your child have a written Asthma Action Plan?
More than 2 times a week
Yes
No
Every night
Don’t know
11. Does your child use a peak flow meter (something he/she blows into to check his/her lungs)?
Yes
No
Don’t know
Yes  what is it? _____
12. Do you know what your child’s personal best peak flow number is?
No
13. Please list the medications your child takes for asthma or allergies (everyday and as needed)
or include a copy of your child’s asthma action plan.
Medications Taken at Home
How Much?
When is it Taken ?
Medication Name ?
Medications to be Taken at School
How Much?
When Should it be Taken ?
Medication Name ?
THE ATTACHED MEDICATION ADMINISTRATION FORM SIGNED BY PARENT/GUARDIAN AND
CHILD’S HEALTHCARE PROVIDER IS NECESSARY TO ADMINISTER MEDICATION AT SCHOOL
(attached).
Please list anything else you use for your child’s asthma (tea, herbs, home remedies, etc.):
________________________________________________
14. How well does your child take his/her asthma medications?
Can take medicine by self
Forgets to take medicine
Needs help taking medicine
Not using medicine now
15. Does your child usually use a spacer or holding chamber with his metered dose inhaler (a clear tube that attaches to the inhaler
and better helps the inhaled medicine get into the lungs)?
Yes
No
Don’t know
16. During the past year has your child’s asthma ever stopped him/her from taking part in sports, recess, physical education or other
school activities?
Yes
No
Don’t know
17. Do you want to talk to the school nurse more about asthma?
If so, what is the best time to call you:?
Morning
Yes
Afternoon
No
Evening
Please call the District Nurse with questions:
Phone #
619-669-2753 Fax #
619-669-7632
Thank you for filling out this questionnaire.
Asthma Action Plan
Jamul-Dulzura Union School District
Name:
Birth Date:
Date:
Fax #:
Provider Phone #:
Patient Goal:
Parent/Guardian Phone #:
Important! Things that make your asthma worse (Triggers): □ dust □ pets □ mold
□ smoke
□ pollen □ colds/viruses
□ other ______________
Severity: □ Severe Persistent □ Moderate Persistent □ Mild Persistent □ Mild Intermittent
GO – You’re Doing Well!

Use these medicines everyday:
PERSONAL BEST PEAK FLOW: __________
You have all of
Personalt Peak Flow: ________
these:
 Breathing is good
MEDICINE
Peak flow
 No cough or
from
OFTEN/WHEN
OR
wheeze
_______
 Sleep through
the night
to
_______
 Can work
and play
CAUTION – Slow Down! 
You have any of
these:
 First signs of a
cold
 Exposure to
known trigger
 Cough
 Mild wheeze
 Tight chest
 Coughing at night
OR
HOW
Puffs
Tabs
Nebulizer
Xs per day
AM PM
Puffs
Tabs
Nebulizer
Xs per day
AM PM
Continue with green zone medicine and add:
MEDICINE
OFTEN/WHEN
HOW MUCH
HOW
Puffs
Tabs
Nebulizer
to
_______
Xs per day
AM PM
Puffs
CALL YOUR HEALTH CARE
PROVIDER:
DANGER – Get Help!
now.
Your
Asthma is
 Coughing
getting
worse
at night
fast:
 Medicine is not
helping
 Breathing is
hard and fast
 Nose opens
wide
 Ribs show
 Can’t talk
well
Peak flow
from
_______
HOW MUCH
OR

Peak flow
Less than
_______
Tabs
Nebulizer
Xs per day
AM PM
Take these medicines and call your provider
MEDICINE
OFTEN/WHEN
HOW MUCH
Puffs
Tabs
Nebulizer
HOW
Xs per day
AM PM
Puffs
Xs per day
Get help from a provider now!
Tabs Do not be afraid
AM PM of
Nebulizer
causing a fuss. Your provider
will want to see you
FOR MINORS ONLY:
right away. It’s important! If you cannot contact
 This student is capable and has been instructed in the proper method of self-administering the medications named above.
 This student is not approved to self-medicate.
your provider, go directly to the emergency room
Provider Signature: _______________________________________________________________Date:______________
and bring this form with you. DO NOT WAIT.
Parent Signature: _______________________________________________________________ Date: _____________
Make an appointment with your primary care provider within two days of an ED visit or hospitalization.
AUTHORIZATION FOR MEDICATION ADMINISTRATION JAMULDULZURA UNION SCHOOL DISTRICT
I, the undersigned, as legal parent/guardian of:
_________________________
_______________, _________,
Student’s Last Name
First Name
_________
Middle
Birthdate
________________________, ________________, ______, ______, request that the
School
Teacher
Grade
Room #
listed medications be made available to my child at the prescribed time(s) _______.
I will provide the medication(s) in the prescription container(s), which is labeled with the name of my child, the
prescribing physician’s name and the medication with directions for administration (i.e. amount, time, etc.). All
refills will be provided when necessary. I understand that it is my responsibility to keep the supply of
medication current.
If any of the conditions in the physician’s statement change, I will ensure a new form is completed and signed
by the physician and myself.
I understand that prescription and non-prescription medications are not permitted to be taken at school by the
student without assistance and without a written statement from the physician and the parent requesting that
the district assist the student as set forth in the physician’s statement below.
This form is valid for School Year ______/________.
__________________________________ _________
Parent / Guardian Signature
Date
______________________________________ ________________ ______________
Address
Home Phone
Work Phone
This portion to be completed by a California licensed physician
Medication is prescribed for the school year (
) unless stated otherwise
Name of Medication
Method of Administration
Dosage
Time of Day
1. __________________
___________________
____________ _____________
2. __________________
___________________
____________ _____________
3. __________________
___________________
____________ _____________
Medication is for treatment of: _________________________________________________
The medication will affect the student by: _________________________________________
The side effects of the medication are: ___________________________________________
Consequences of not taking the medication are: ____________________________________
___________________________ ___________________________ ______________
Print Physician’s Name
California Medical License Number
Date
__________________________ __________________ ____________ ___________
Physician’s Signature
Phone Number
Best time to call
Fax Number
THIS MEDICATION PROCEDURE COVERING PRESCRIPTION AND NON-PRESCRIPTION MEDICATION
WILL BE EXPEDITED UNDER THE FOLLOWING CONDITIONS:
 Written permission is required of the parent/guardian and the attending physician.
 Medication and completed authorization form shall be delivered to the school by the parent, a
designated adult or responsible pupil.
 Medication shall be received and documented by designated staff member.
 The student will be assisted with medication in accordance with instruction from the physician.
 Medication delivered at school shall be in its prescription containers, which are clearly labeled with the
pupil’s name, the name of the prescribing physician, the pharmacist dispensing the medication or the
manufacturer, and the amount of medication to be taken at specific times or in specific situations, etc.
(Pharmacist will provide a duplicate labeled bottle when requested, one for home and one for school).
 All medication will be kept in a secure (locked) cabinet/drawer. Any special instructions for storage or
security measures of any medication shall be written by the physician for designated staff members to
follow.
 A new completed Authorization for Medication form must be completed for each school year if a
continuance of medication is requested.
AUTHORIZATION FOR MEDICATION ADMINISTRATION
(EDUCATION CODE SECTION 49423)
Any pupil who is required to take, during the regular school day, medication prescribed for him/her by a
physician, may be assisted by a school nurse or other designated school district personnel if the district
receives:
1. A written statement from a physician licensed in the State of California detailing the method,
amount, and time schedules by which such medication is to be taken. (See the reverse side of this
form)
2. Written authorization from the parent/guardian of the pupil indicating the desire that school district
personnel assist the pupil in the matters set forth in the Physician’s Statement (See the reverse side
of this form)
This authorization is valid only for the current school year. If any of the conditions in the Physician’s
Statement change, the parent/guardian and the physician must sign a new form.
Only medication prescribed by the pupil/s physician as being necessary to be taken by the pupil in the
manner listed on the Physician’s Statement shall be brought to the school. Medication shall be in
containers that are clearly marked with the name of the pupil, the name of the prescribing physician, name
of the medication, and the amount of medication.