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Asthma Action Plan

 

Your name:

_________________________

Emergency contact:

_________________________

Healthcare provider:

_________________________

Today's Date:

_________________________

Phone:

_________________________

Signature:

_________________________

Next appt (date/time):

_________________________

Phone:

_________________________

Phone:

_________________________

Green zone

My symptoms

What I should do

My medicine

  • No wheezing, coughing, or chest tightness

  • Asthma is not bothering your sleep, work, or school

  • You rarely or never use your quick-relief medicine

Peak flow is:

 

_____________________

80%-100% of personal best

  • Keep taking your long-term  controller medicines

  • Take your quick-relief
    medicines as needed

Avoid your asthma triggers (list):

_______________________

 

_______________________

 

_______________________

 

_______________________

 

_______________________

Long-term controllers:

__________________________

Name:

__________________________

Dose:

__________________________

How often:

__________________________

Special instructions:

__________________________

Quick-relief:

__________________________

__________________________

Before exercise:

__________________________

 

Yellow zone

My symptoms

What I should do

My medicine

  • Some wheezing, coughing, or chest tightness

  • When at rest, your breathing is a little faster than normal

  • Asthma symptoms wake you up at night

Peak flow is:

 

______________________

50%-80% of personal best, or
has lessened by at least 15%

 

You begin to have symptoms of a respiratory infection, if infections trigger your symptoms

  • Keep taking your long-term controller medicines

  • Use your quick-relief medicine

  • If you do not feel better within an hour after using your quick-relief medicine, make sure you know what to do! You might use more medicine or use another medicine.

  • Call your healthcare provider if you are unsure

Continue to take long-term controllers:

_________________________

Name:

_________________________

Dose:

_________________________

How often:

_________________________

Special instructions

_________________________

 

Name:

_________________________

Dose:

_________________________

How often:

_________________________

Special instructions:

_________________________

Quick-relief:

_________________________

_________________________

 

If your symptoms don't go away after 1 hour, take:

_________________________

 

Red zone

My symptoms

What I should do

My medicine

  • Continuous wheezing, coughing, or trouble breathing

  • Trouble walking or talking

  • Asthma symptoms make it hard for you to sleep

 

Peak flow is:

 

_________________

Less than 50% of personal best

  • Use your quick-relief medicines

  • Call your healthcare provider

 

Call 911 if:

  • It is getting harder to breathe

  • You can't walk or talk

  • Your lips or fingers look gray or blue

Quick-relief:

__________________________

__________________________

 

Quick-relief:

__________________________

__________________________

 

Quick-relief:

__________________________

__________________________

 

Online Medical Reviewer: Holloway, Beth, RN, M.Ed.
Online Medical Reviewer: MMI board-certified, academically-affiliated clinician
Last Review Date: 6/16/2014
© 2000-2016 The StayWell Company, LLC. 780 Township Line Road, Yardley, PA 19067. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.