American Lung Association Asthma Action Plan
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1Asthma Action Plan
Name _____________________________________________________________________________________________________________________
DOB ______ /______ /____________
Severity Classification
Intermittent
Mild Persistent
Moderate Persistent
Severe Persistent
Asthma Triggers (list) ________________________________________________________________________________________________________________________
Peak Flow Meter Personal Best ____________
Green Zone: Doing Well
Symptoms: Breathing is good – No cough or wheeze – Can work and play – Sleeps well at night
Peak Flow Meter ________ (more than 80% of personal best)
Control Medicine(s)
Medicine
How much to take
When and how often to take it
__________________________________________
__________________________________ __________________________________
__________________________________________
__________________________________ __________________________________
Physical Activity
Use albuterol/levalbuterol _____ puffs, 15 minutes before activity
with all activity
when you feel you need it
Yellow Zone: Caution
Symptoms: Some problems breathing – Cough, wheeze, or chest tight – Problems working or playing – Wake at night
Peak Flow Meter ________ to ________ (between 50% and 79% of personal best)
Quick-relief Medicine(s) Albuterol/levalbuterol _____ puffs, every 4 hours as needed
Control Medicine(s)
Continue Green Zone medicines
Add ____________________________________________
Change to ______________________________________________
You should feel better within 20–60 minutes of the quick-relief treatment. If you are getting worse or are in the Yellow Zone for
more than 24 hours, THEN follow the instructions in the RED ZONE and call the doctor right away!
Red Zone: Get Help Now!
Symptoms: Lots of problems breathing – Cannot work or play – Getting worse instead of better – Medicine is not helping
Peak Flow Meter ________ (less than 50% of personal best)
Take Quick-relief Medicine NOW!
Albuterol/levalbuterol _____ puffs, ___________________________________________ (how frequently)
Call 911 immediately if the following danger signs are present • Trouble walking/talking due to shortness of breath
• Lips or fingernails are blue
• Still in the red zone after 15 minutes
Emergency Contact
Name ______________________________________________________________________________________ Phone (_____________) _____________-__________________
Healthcare Provider
Name _______________________________________________________________________________________ Phone (_____________) _____________-__________________
1-800-LUNGUSA |
Date ______ /______ /____________
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