WESTERN RACINE COUNTY HEALTH DEPARTMENT
156 East State Street
Burlington, WI 53105
(262) 763-4930 or (800) 688-4930
PARENT INTERVIEW
Date __________________________
School __________________________________ Grade _________ Teacher ________________________________
Parent’s Name(s) _____________________________Telephone (home) ___________ Telephone (work) __________
The following information is helpful to your child’s school nurse and school staff in determining any special needs for your child.
Please answer the questions to the best of your ability. If you desire a conference with the school nurse, please call for an appointment.
Nurse’s Name ___________________________________________ Telephone Number ______________________
1. How long has your child had asthma? __________________________________________________________
Has child been diagnosed by MD? ____________________________________________________________
2. Please rate the severity of his/her asthma (circle)
(Not Severe) 0 1 2 3 4 5 6 7 8 9 10 (Severe)
3. How many days would you estimate he/she missed school last year due to asthma? _____________________
4. What triggers your child’s asthma attacks? (Please check any that apply.)
___Animals ___Cigarette or Other Smoke ___Chemical Odors ___Emotions ___Exercise
___Fatigue ___Foods (Specify) ___Weather (Specify) ___Illness ___Medications
5. What does your child do at home to relieve wheezing during an asthma attack? (Please check any that apply.)
___Breathing Exercises Takes Medication: ___Inhaler
___Rest/Relaxation ___Nebulizer
___Drinks liquids ___Oral medication
Other (describe)___________________________________________________________________________
6. Please list the medications your child takes for asthma (everyday and as needed).
Name of Medication Dose Frequency Location Of Inhaler At School
(In School ) ____________________________________________________________________________________
(At Home) _____________________________________________________________________________________
If medications are to be given during school, a medication permission slip needs to be filled out yearly and when changes are made.
Medications must be in the original labeled container. (When you get prescriptions filled you can ask the pharmacist to put them
into two containers so you’ll have one for school and one for home use.)
7. If your child does not respond to medication, what actions do you advise school personnel to take?
________________________________________________________________________________________
8. What, if any, side effects does your child have from his/her medications? _____________________________
9. Has your child been taught how to use an extension tube, pulmonary aid, inspirease kit or other device with his/her inhaler?
YES NO Device(s)_______________________________________________
10. How many times has your child been hospitalized overnight or longer for asthma in the past year? _________
11. How many times has your child been treated in the emergency room for asthma in the past year? __________
12. How often does your child see his/her doctor for routine asthma evaluations? __________________________
13. Does your child need any special considerations related to his/her asthma while at school? (Check any that apply and describe briefly.)
Modified gym class ________________________________________________________________________
Modified recess outside (when) ______________________________________________________________
No animal pets in classroom _________________________________________________________________
Avoiding certain foods______________________________________________________________________
Emotional or behavior concerns ______________________________________________________________
Special consideration while on field trips _______________________________________________________
Special transportation to and from school _______________________________________________________
Observation for side effects from medication ____________________________________________________
Other ___________________________________________________________________________________
14. Do you know what your child’s baseline peak flow rate is? YES NO Rate ________________
15. Do you think your child holds him/herself back from participating in any activities at school because of his/her asthma? If so, please describe.
_______________________________________________________________________________________
16. Have you ever attended an asthma education class? YES NO
Would you be interested in attending one? YES NO
Has your child had asthma education? YES NO
Would you be interested in having your child attend one? YES NO
Would you be interested in a support group for asthmatics? YES NO
Thank you for your time and assistance in assessing your child’s special needs in school.
Adapted from: The School Nurse’s Source Book of Individualized Healthcare Plans, Marykay Haas.