Asthma Action Plan Template - Vermont Department Of Health
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Asthma Action Plan
________________________________________________________________
Type of Asthma*
Intermittent
Mild Persistent
(check)
Action Plan for
Date
Moderate Persistent
Severe Persistent
________________________________________________________________
Emergency Contact Name & Phone
Year Diagnosed _________
________________________________________________________________
Pulmonary Function Testing Date _________
Medical Provider Name & Phone
Peak Flow (PF) _________ Pneumovax Date _________
________________________________________________________________
Pharmacy Name & Phone
Allergy Testing Date _________ Flu Vaccine Date _________
________________________________________________________________
Other Vaccines Date ___________________________________
Allergies/Triggers (check all that apply): Based on self report by patient and/or confirmed by allergist
Cigarette Smoke
Air Pollution
Hot/Cold Air
Exercise
Cockroaches
Dust Mites
Food
Heartburn
Tree/Grass Pollen
Strong Odors
Emotional Stress
Animals
Medication
Infections
Mold
Other__________
Comments:
* For additional information on the types of asthma go to
I, ____________________________________ give permission to ____________________________________ to exchange
information and otherwise assist in my asthma management including direct communication with my medical provider.
Signature ___________________________________ Relationship to client ____________________ Date ___________
Medications can be administered per this action plan, including allowing the client to self-administer medications.
Medical Provider Signature ___________________________________ Date ___________
GO You are doing well!
Daily Medicine
Medicine/Treatment
How Much
How Often
Go if you have all of these:
• PF above ________
• Breathing is good
• No cough or wheeze
• Can sleep through the night
• Can work/play
10-15 minutes before physical activity, use:
CAUTION – Slow down.
Daily Medicine
Medicine/Treatment
How Much
How Often
Caution if you have any of these:
• PF from ______ to ______
• First sign of a cold
• Cough or mild wheeze
• Tight chest
• Coughing at night
If not better within 24 hours, call your medical provider.
STOP
Get help!
Take These Medications & Seek Medical Help
Medicine/Treatment
How Much
How Often
STOP your asthma is getting worse fast:
• PF below ________
• Medicine is not helping
• Very short of breath
• Cannot talk well
This could be a life threatening emergency!
• Same or worse symptoms
after 24 hours in yellow zone
You may need to go to the Emergency Department or call 911.
healthvermont.gov
toll free 1 866 331 5622
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