Asthma Questionnaire

Student's First Name*

Student's Last*

When was your child last asthma attack?*

Does your child use an inhaler regularly?*

Yes No

Where would you prefer your child's inhaler located during school hours?*

Nurse's office (Please supply the school nurse with an inhaler orientation day.) With my child Both (Please supply the 2 inhalers on orientation day.)

Emergency Contact Name*

Emergency Contact #*

Emergency Contact Email*