Child Asthma Action Plan Form
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1
2Patient Name: ____________________________________________
DOB: ___________________________________________________
My Asthma Action Plan
Healthcare Provider’s Name: ________________________________
Healthcare Provider’s Phone #: ______________________________
Ages 6 and Older:
Review and update at each Doctor’s visit
I feel good
PREVENT asthma symptoms everyday:
Avoid things that make my asthma worse
I measure my peak flow daily and I am
Take my controller medicines everyday:
in the
GREEN zone)
MEDICINE
HOW MUCH
WHEN
100%
• No coughing
My Personal
or wheezing
Best Peak Flow
Best Peak Flow
• Breathing easy
Optional Instructions:
• I can play and work
Before exercise take
2
4 puffs
RESCUE MEDICINE
At the onset of respiratory illness,
Take
puffs
times a day for
days
ICS
I do not feel well
CAUTION, asthma symptoms are present or my peak flow is
between 50–80%
80% of My
Take
2
4 puffs
nebulizer,
I need to measure my peak flow
Personal Best
RESCUE MEDICINE
every 20 minutes for up to 1 hour, as needed
My symptoms include one or more of the following:
If you feel better and are back in the Green Zone continue your
If you feel better and are back in the Green Zone continue your
If you feel better
• Wheeze
Green Zone medicines
• Tight chest
If symptoms persist take
• Cough
RESCUE MEDICINE
• Shortness of Breath
2
4 puffs
nebulizer, every
hours for 1–2 days
• Waking up at night
If you still do not feel well and you continue to need your rescue
If you still do not feel well and you continue to need your rescue
If you still do not feel well
with asthma symptoms
medicine for more than
hours, call your doctor and take the
• Decreased ability to
following medicines:
do usual activities
Take
puffs
times a day for
days
ICS
If symtoms occur more than
Take
times a day for
days
twice a week call your doctor.
ORAL STEROID
Continue all other Green Zone medicines
If symptoms worsen call your doctor
I feel awful!
DANGER! Your peak fl ow is less than 50%.
Get help immediately.
50% of My
50% of My
I need to measure my peak flow
Take
Personal Best
Personal Best
RESCUE MEDICINE
Warning signs may include
2
4 puffs
nebulizer, every 20 minutes
one or more of the following:
Call your Doctor’s offi ce now.
• It’s getting harder and
If you can’t reach them, go to the hospital
harder to breathe
• Unable to sleep or do
usual activities because
Call 911 if you have trouble walking or talking
of trouble sleeping
due to shortness of breath or lips/fi ngernails are
grey or blue
Completed by:
Date:
AUTHORIZATION AND DISCLAIMER FROM PARENT/GUARDIAN: MY CHILD
MAY CARRY AND SELF-ADMINISTER ASTHMA MEDICATIONS
YES
NO AND
I AGREE TO RELEASE THE SCHOOL DISTRICT AND SCHOOL PERSONNEL FROM
ALL CLAIMS OF LIABILITY IF MY CHILD SUFFERS ANY ADVERSE REACTIONS
Parent Signature:
Date:
FROM SELF-ADMINISTRATION OF ASTHMA MEDICATIONS.
PHYSICIAN: MY SIGNATURE PROVIDES AUTHORIZATION FOR THE ABOVE
WRITTEN ORDERS. STUDENT MAY CARRY AND SELF-ADMINISTER ASTHMA
Physician Signature:
Date:
MEDICATIONS
YES
NO.
FOR MORE INFORMATION ON CHILDHOOD ASTHMA VISIT OUR WEBSITE AT:
TOP SHEET: PATIENT
SECOND SHEET: CHILD CARE/SCHOOL/OTHER SUPPORT SYSTEM
LAST SHEET: MEDICAL RECORD
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