Adult Asthma Action Plan (English, Spanish, Chinese Forms)
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My Asthma Plan
N
,
Physician's Name:
_ _ _ _ _
__
__ _ _ _ _ _ _ _
Physician's
Phone
#: _
__
__ _ _ _ _ _ _ _
Completed by: _ _ _ _ _ _ _ _ _ _ _ Date:
_ _
__ _
~
Controller Medicines
How Much
to
Take
How Often
Other Instructions
_ _
times per day
EVERYDAY!
_ _
times
per day
EVERYDAY!
_ _
times
per day
EVERYDAY!
_ _ times per day
EVERYDAY!
Quick-Relief Medicines
How Much to Take
I
How Often
Other
Instructions
NOTE:
If
this medicine
i~
needed
frequently,
(all
physician to
consider
Take ONLY as needed
increasinci"controJler medications.
Special instructions when
I
feel
.
good,
0
not
good,
and
0
awful.
w
z
2
~
w
>-
I
teel
£O(ut._
(My
peak flow is
in the
GREEN
lone.)
I do
not
teel
good.
(My
peak flow
is in the
YellOW zone.)
My symptoms
may include
one
or more of the following:
•
Wheeze
•
Tight chest
•
Cough
•
Shortness
of
breath
•
Waking up at night with
asthma symptoms
•
Decreased
ability
to do
usual
activities
•
I teel
awful.
(My
peak flow
is if!
the
RED
zone.)
Warning signs may include one or
,""""",,,,11
more
of
the
following:
•
Its
getting harder and harder
to
breathe
lil".!"';n.
ORIG
INAL
(Pat;..nt)
CANARY (School
I
Child
Car.
I Work I Otlll'r Support SYltem,)
PREVENT
asthma symptoms everyday:
D
Take my controller medicines
(above)
everyday.
D
Before exercise, take
_ _
puffs
of _ _ _ _ _ _ _ _
D
Avoid
things
that make my
asthma worse like:
CAUTION.
I
should continue
taking my
everyday controller
asthma medicines AND:
o
Take
_ _ _ _ _ _ _ _
__
_ _ _
If
I
still do not feel good, or my peak
flow is
not back in the
Creell ZOlle within one hour, then I
should:
D
Inctease
_
__
__ _ _ _ _ _ _ _ _ _ _
o
Add
_ _ _ _ _ _ _ _ _ _ _
_
o
(all
_ _ _ _ _ _ _ _ _ _ _
__
_
MEDICAL ALERT! Cet lie/pI
o
Take_--c-c-:-_::-::-_ _ _ _ _ _ _
until I
get
help immediately.
o
Take
_ _ _ _ _ _ _ _ _ _ _ _ _
PINK
(Ci,,"t)
~2
001
.
Public
H
ealth
In,titutt
(RAMP)
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