Cardiac Emergency Plan Student Name:(Required) Student Grade Level:(Required) Student Age:(Required) Diagnosis(Required)Medical History:(Required)RECOMMENDATIONS FOR PHYSICAL ACTIVITY (Must be completed by the doctor) Activity Level (Please mark the box that applies) May participate in the entire physical education program (PE class) without restriction, including competitive sports. May participate in the entire PE program *May not participate in competitive sports where there is strenuous training and prolonged physical exertion(e.g soccer, basketball, tennis) May participate in the PE class except for excessively stressful activities such as rope climbing,weight lifting,sustained running(e.g. laps)and fitness testing. May participate in mild PE class activities such as circle games, badminton, yoga, walking, mild exercises, hula hoop Restricted from the entire PE class program and all recreational, and sports Duration of recommendations: Additional Remarks:Physician Name: Guidelines for use of supplemental oxygen while in the school(Must be completed by the doctor)List of medications, dosage and frequency, common side effects.(Must be completed by the doctor)EMERGENCY ACTIONS A cardiac emergency requires immediate action. Cardiac emergencies may arise as a result of a Sudden Cardiac Arrest (SCA) or a heart attack, but can have other causes. WHAT TO DO Signs and symptoms of cardiac stress: Shortness of breath Dizziness Chest pain Skin: pale or bluish color Fatigue/tires easily Anxiety; a feeling of impending doom Sweating Numbness or tingling in arms Sudden collapse IF CONSCIOUS, ALERT, NO APPARENT DISTRESS IF UNCONSCIOUS / UNRESPONSIVE, FAINTS, or has URGENT DIFFICULTY BREATHING Notify the clinic immediately. Mobile numbers: 09894082266-09420751274 Allow student to rest in a comfortable position Have him take slow, deep breaths and relax as much as possible. Reassure him and keep calm. If symptoms do not improve after 10 minutes, notify parents immediately. Call for help and ask someone to grab the AED (location: clinic, gym, swimming poool) Stay with student and begin First Aid/CPR Send for the Nurse/Doctor and state student’s name Notify Administration Nurse, doctor /Administration will notify parents Student must receive medical emergency care and must be transported to the hospital Prevention Measures: Ensure the student’s medication list is up-to-date and they are taking their blood thinner medication as prescribed. Encourage the student to avoid strenuous physical exertion and extreme temperatures. Discuss with the student’s healthcare provider the importance of regular follow-up appointments and monitoring of their heart condition. Educate the student on the signs and symptoms of an emergency situation and what actions to take. Parent/Guardian Name:(Required) Parent/Guardian Phone:(Required) Parent/Guradian Email:(Required) Parent/Guardian Signature:(Required)Date(Required) MM slash DD slash YYYY Emergency Contact Name: Emergency Contact Email: Emergency Contact Phone: Relationship to Student: