Asthma Action Plan Template
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1Asthma Action Plan
General Information:
■ Name _____________________________________________________________________________________________________
■ Emergency contact _______________________________________________________ Phone numbers _________________________
■ Physician/healthcare provider ________________________________________________Phone numbers _________________________
■ Physician signature _______________________________________________________ Date _________________________________
Severity Classification
Triggers
Exercise
❍ Intermittent
❍ Moderate Persistent
❍ Colds
❍ Smoke ❍ Weather
1. Premedication (how much and when) ______
❍ Mild Persistent
❍ Severe Persistent
❍ Exercise ❍ Dust
❍ Air Pollution
___________________________________
❍ Animals ❍ Food
2. Exercise modifi cations _________________
❍ Other ______________________
___________________________________
Green Zone: Doing Well
Peak Flow Meter Personal Best =
Symptoms
Control Medications:
■ Breathing is good
Medicine
How Much to Take
When to Take It
■ No cough or wheeze
■ Can work and play
■ Sleeps well at night
Peak Flow Meter
More than 80% of personal best or __________
Yellow Zone: Getting Worse
Contact physician if using quick relief more than 2 times per week.
Symptoms
Continue control medicines and add:
■ Some problems breathing
Medicine
How Much to Take
When to Take It
■ Cough, wheeze, or chest tight
■ Problems working or playing
■ Wake at night
Peak Flow Meter
IF your symptoms (and peak fl ow, if used)
IF your symptoms (and peak fl ow, if used)
return to Green Zone after one hour of the
DO NOT return to Green Zone after one
Between 50% and 80% of personal best or
hour of the quick-relief treatment, THEN
quick-relief treatment, THEN
__________ to __________
❍ Take quick-relief treatment again.
❍ Take quick-relief medication every
4 hours for 1 to 2 days.
❍ Change your long-term control medicine by
______________________________
❍ Change your long-term control medicine by
______________________________
❍ Call your physician/Healthcare provider
within ____ hour(s) of modifying your
❍ Contact your physician for follow-up care.
medication routine.
Red Zone: Medical Alert
Ambulance/Emergency Phone Number:
Symptoms
Continue control medicines and add:
■ Lots of problems breathing
Medicine
How Much to Take
When to Take It
■ Cannot work or play
■ Getting worse instead of better
■ Medicine is not helping
Peak Flow Meter
Go to the hospital or call for an ambulance if:
Call an ambulance immediately if the
following danger signs are present:
Less than 50% of personal best or
❍ Still in the red zone after 15 minutes.
__________ to __________
❍ Trouble walking/talking due to shortness
❍ You have not been able to reach your
of breath.
physician/healthcare provider for help.
❍ Lips or fi ngernails are blue.
❍ ______________________________
Rev_July_2008
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