Montana Student Asthma Action Plan
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1Montana Student Asthma Action Plan
Student_____________________ School Nurse/Emergency Staff Phone_____________ Fax
Teacher_______________________ Parent/Guardian_______________________ Phone
Student’s Healthcare Provider_______________________ Phone______________ Fax
Student is feeling well
No difficulty participating in usual activities
No chest tightness, shortness of breath, wheezing, or coughing during the day or night
Green
Take these controller medications every day:
Zone
Medicine
Dosage
When to Take it
Before exercise: Medication
Dosage
minutes prior to activity
Student is not feeling well
Chest tightness, shortness of breath, wheezing, or coughing with usual activities
Waking at night due to asthma symptoms
Yellow
Continue taking controller medication(s) and add these quick-relief medications:
Zone
Medicine
Dosage
When to Take it
Call student’s healthcare provider if:
Alert! Contact student’s healthcare provider or call 911 if:
Quick-relief medication is not helping
Breathing is hard and fast
Red
Ribs are showing and nostrils are flaring
Zone
Can’t walk or talk well
Take the following medications, and call the healthcare provider or contact EMS right away:
Medicine
Dosage
When to Take it
Other key medical information
Student self-carries rescue medication Rescue medication is stored
The student’s asthma triggers are
Reviewed by parent/guardian
Date
Reviewed by school nurse/emergency staff
Date
Reviewed by student’s healthcare provider
Date
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