Mittagundi asthma form

Mittagundi Asthma Form
Participant’s Name: _______________________________ Date: IMPORTANT INFORMATION FOR PARENTS/GUARDIAN
Asthma is a potentially serious condition. Both you and your child should have a good understanding of the severity of
the Asthma suffered and know how the necessary management practices for Monitoring, Prevention and Relief of
Asthma. This is best established by a visit to your doctor. Your family doctor should take 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 Mittagundi also has a good understanding of your child’s condition in order to assess the risks associated with different activities to your child and also to be able to offer the best possible assistance should an attack occur. For this reason we require that participants who suffer Asthma should have the following information filled out and completed by the family doctor.
IMPORTANT INFORMATION FOR THE DOCTOR
Mittagundi conducts nine day courses in the Victorian High Country which involve bushwalking, cross country skiing,
expeditions in isolated under canvas settings, rafting, abseiling and living on a remote semi self sufficient farm.
Assistance in the worst-case scenario is usually no more than a day away on our most isolated camps. Our staff are
trained in Wilderness First Aid. We have available a back up spacer unit and foot pump nebuliser. We try not to exclude
students from participation due to medical reasons but rather instigate appropriate measures to enable their safe
participation. To assist us in this we require your help in establishing these measures and ensuring the participant is wel
educated about their condition and largely capable of self-management. For further information please feel free to
contact the Mittagundi Directors on (03) 5159 7238.
TO BE COMPLETED BY THE DOCTOR
1. 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 in the past year YES/NO
2. What are the trigger factors for the patient’s asthma?
Food preservatives YES/NO (specify which ones) Food Colourings YES/NO (specify which ones) Artificial Food Flavourings YES/NO (specify which ones) Specific Foods of food groups YES/NO (specify which ones) Please turn over and complete the second page.
Mittagundi Asthma Form continued…
3) What is the preventative plan of management this patient should undertake to prevent the onset of a
major attack?
Warning signs for the onset of an attack: Best strategies for obtaining relief from the attack: 4) What asthma medication does the patient take?
Please circle the Preventer or Reliever (Bronchodilator) medications used by the patient.
PREVENTERS: Becotide, Becloforte, Aldecin. Pulmicort. Intal or Intal Forte
Other:_____________________________________________
RELIEVER: Bricanyl, Respolin, Ventolin, Atrovent,
Other_____________________________________
Declaration:
I am aware of and understand the information in this form. I declare this information is true and correct at time
of consultation.
Please ensure that the patient has sufficient medication for the duration of the program
All of the above Medical Information will be treated in confidence.
Thank you for your assistance.

Source: http://www.mittagundi.org.au/forms/asthmaform.pdf