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Suncoastcc.qld.edu.au

MEEBUNN-BIA OUTDOOR EDUCATION INC
ASTHMA MANAGEMENT FORM (Page 1/3)
Surname: _______________________________ Given Name: ______________________________ School / Organisation: ____________________________________________________________________ IMPORTANT INFORMATION FOR PARENTS
Asthma is a potentially serious condition. Both you & your child should have a good understanding of the severity of the Asthma suffered and know the necessary management practices for Monitoring, Prevention & Relief of Asthma. This is best established by a visit to your family doctor. Your family doctor should take you and your child through the “National Asthma Campaign’s Six Step Asthma Management Plan” and should complete an Asthma Action Plan card to be carried by the patient at all times. It is essential that Meebunn-bia also has a good understanding of your child’s conditions in order to be able to asses the risk associated with different activities to your child & also to be able to offer the best possible assistance should an attack occur. For this reason, we require that all participants who suffer from Asthma complete the following questions. FIVE KEY QUESTIONS
1. Has your child ever been hospitalised or required urgent medical attention for their asthma? 2. Does your child require asthma medication on a daily basis? 3. Does your child wake regularly at night due to their asthma? 4. Is your child’s peak flow consistently below expected level despite optimal treatment? 5. Is your child unable to confidently self-manage their asthma? IF “YES” WAS TICKED FOR ANY OF THE 5 KEY QUESTIONS PLEASE COMPLETE PAGES 2
& 3 WITH YOUR FAMILY DOCTOR.
IF YOU TICKED “NO” FOR ALL OF THE FIVE KEY QUESTIONS PLEASE COMPLETE
BELOW. (Do not complete pages 2 & 3)
TO BE COMPLETED BY THE PARENTS / GUARDIAN
WHAT ARE THE TRIGGER FACTORS FOR YOUR CHILD’S ASTHMA?
Animal Fur
Yes  No  (Specify)_________________________________________ Yes  No  (Specify)_________________________________________ Yes  No  (Specify)_________________________________________ Specific Food or Food Groups Yes  No  (Specify)_________________________________________ Exercise Induced Asthma Yes  No  (Specify)_________________________________________ Any other known trigger factors? ___________________________________________________________ WHAT ARE YOUR CHILD’S USUAL SYMPTOMS OF ASTHMA?
Wheezing
MEDICATION INFORMATION
Preventer -
___________________________________________________________________________
Reliever - _______________________________________________________________________
Where is the Medication Located? __________________________________________________
Please Ensure that your child has enough medication for the duration of the program. Thankyou.

mydocs/originals/medicalforms/asthma: November 2002 MEEBUNN-BIA OUTDOOR EDUCATION INC
ASTHMA MANAGEMENT FORM (Page 2/3)
Surname: _______________________________ Given Name: ______________________________ School / Organisation: ____________________________________________________________________ IMPORTANT INFORMATION FOR THE DOCTOR
Programs conducted at Meebunn-bia involve a high level of physical activity and are conducted out of doors. Meebunn-bia is a 45 minute drive from the nearest ambulance, doctor or hospital but in most instances, the response time for medical attention may exceed 3 hours. Our staff are trained to a Senior First Aid level & carry a First Aid Kit which contains a ventolin puffer. We try not to exclude students from participation due to medical reasons but rather try to instigate appropriate measures to enable them to participate safely. To achieve this we require your assistance in establishing these measures and ensuring the student is as educated as possible about their condition and is largely capable of self management. If you would like further information please feel free to contact us on (07) 5541 2820 TO BE COMPLETED BY THE DOCTOR
Doctor’s Name:
Work Phone Number: 24 Hour Emergency Contact Number:

In order to help you assess the risks involved in the patient’s participation and in developing any subsequent
plan of management, a program summary is included below.
Time of Year: Duration (Days):
Accommodation type:
Building, Tent, Fly (Hootchie), Other
Program Activities: High Adventure (eg. abseiling, high ropes courses, flying fox, giant swing), Canoeing,
Bushwalking, Other:
HOW SEVERE IS THE PATIENT’S ASTHMA?
Patient requires Asthma Medication most weeks of the year Yes No Patient wakes regularly at night with asthma Yes No Patient has required urgent medical attention for Asthma in the past year Yes No Patient’s peak air flow is consistently below level expected despite optimal treatment Yes No WHAT ARE THE TRIGGER FACTORS FOR THE PATIENT’S ASTHMA?
Yes  No  (Specify)___________________________________________________ Yes  No  (Specify)___________________________________________________ Yes  No  (Specify)___________________________________________________ Specific Food or Food Groups Yes  No  (Specify)__________________________________________________ Exercise Induced Asthma Yes  No  (Specify)___________________________________________________ Any other known trigger factors? _____________________________________________________________________ mydocs/originals/medicalforms/asthma: November 2002 MEEBUNN-BIA OUTDOOR EDUCATION INC
ASTHMA MANAGEMENT FORM (Page 3/3)
(All information is treated with the utmost confidentiality)
Surname: Given Names:
TO BE COMPLETED BY A DOCTOR (continued)
In order for Meebunn-bia staff to lend any assistance to a person in distress they need the following information to be completed and a preventative plan of management to follow, specific to the program and the participant; (Meebunn-bia staff have been trained in the 4x4x4 protocol for the emergency treatment of an asthma attack – 4 puffs of reliever through a spacer – to every 1 puff into the spacer the patient takes 4 inhalations through it – wait 4 minutes, if no improvement give another 4 puffs as described. If no improvement treat as an emergency – contact emergency services and continue treatment PLAN OF MANAGEMENT
Preventative steps to avoid attack:
Warning signs for the onset of an attack:
Best Strategies for obtaining relief from the attack:
WHAT ASTHMA MEDICATION DOES THE PATIENT TAKE?
Please circle the Preventer, Reliever (Bronchodilator) or Symptom Controllers used by the patient: PREVENTERS: Becotide, Belcoforte, Tilade, Pulmicort, Intal or Intal Forte (Other _____________) RELIEVERS: Ventolin, Airomir, Asmol, Respax, Bricanyl (Other ________________________) SYMPTOM CONTROLLERS: Serevent, Foradile, Oxis (Other ____________________________) ORAL CORTICOSTEROIDS: Prednisone, Prednisolone (Other ____________________________)
Where is the Medication located? (Pack, Fridge etc)
Please list any storage requirements to prevent spoilage of medication:
An Action Plan Card MUST be filled out and carried by the student at all times. The MBB Instructor
carries with them a copy of this form as well as the patient’s Medical/Consent form. Can you duplicate the
details of the Asthma Action Plan Card and any other details relating to the specific Monitoring,
Prevention and Care of this persons condition in the space below. This information is kept private and
confidential. For Asthma Action Plan Cards contact the National Asthma Campaign on 1800 032 495

Measure Peak Flow before Reliever Best Peak Flow
PEAK FLOW TREATMENT
Below _______________ Double Dose of Preventer
Below _______________ Start Reliever & Contact Doctor
Below
_______________ Continue Reliever & Call an Ambulance immediately
In your professional opinion do you think the patient’s condition is too extreme to be safely managed
on a program of this nature? Yes No
Doctor’s Signature: Date: / /

Meebunn-bia Outdoor Education, PO Box 289, Beaudesert, QLD, 4285
Phone/Fax (07) 5541 2820 email: admin@meebunnbia.com.au
mydocs/originals/medicalforms/asthma: November 2002

Source: http://www.suncoastcc.qld.edu.au/downloads/Asthma%20Management%20Form%20(3).pdf

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