Asthma Action Plan Template
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1Asthma Action Plan
Child’s Name:_________________________ Birthdate:_________ Grade:
School:_______________________
The following is to be completed by the PHYSICIAN:
1. Asthma severity (circle one): mild intermediate _mild persistent
_moderate persistent
severe persistent
2. Medications (at school AND home):
A. QUICK-RELIEF” Medication Name
MDI, oral, neb?
Dosage or No. of Puffs
1.
2.
B. ROUTINE Med Name (eg, anti-inflammatory)
MDI, oral, neb?
Dosage or No. of Puffs
Time of day
1.
2.
C. BEFORE PE, EXERTION Medication Name
MDI, oral, neb?
Dosage or No. of Puffs
1.
2.
3.
For student on inhaled medication (all students must go to health office for oral medications):
[ ] Assist student with medication in office [ ] Remind student to take medication [ ] May carry own medication, if responsible
4.
Circle Known Triggers: tobacco pesticide animals birds dust cleansers car exhaust perfume mold cockroach cold air
cleansers
exercise
Other:__________
5.
Peak Flow: Write patient’s personal best peak flow reading under the 100% box (below); multiply by .8 and .5, respectively
Yellow Zone
Red Zone
Green
100%
80%
50%
Zone
Starting to cough, wheeze or feel
Cough, short of breath, trouble walking or talking
Peak flow =
Peak
Peak
short of breath.
Action for home or school:
flow =
flow =
No
Action for home or school: Give
Take quick-relief meds;
Symptoms
quick-relief med; notify parent.
-If student improves to yellow zone, send student to
______
_______
______
doctor or contact doctor.
Action for Parent/MD: Increase
-If student stays in red zone, begin Emergency Plan.
controller dose______________
School Emergency Plan: If student has: a) no improvement 15–20 minutes AFTER initial treatment with quick-relief medication,
b) Peak flow of < 50% of usual best, c) trouble walking, or talking, or d) chest/neck muscle retractions with breaths, hunched, or blue
color, then: 1) Give quick-relief meds; repeat in 20 minutes, if help has not arrived; 2) Seek emergency care (911); 3) Contact parent.
In yellow or red zone? Students with symptoms who need to use quick-relief meds frequently may need change in routine controller
medication. Schools must be sure parent is aware of each occasion when student had symptoms and requires medication.
†
Physician’s
Name (print): ________________________ Signature:
Date:
Office Address:
Office Telephone:
†
Includes nurse practitioner or other health care provider as long as there is authority to prescribe.
A form that permits school and health care provider to
exchange information must accompany this form.
Parent/Guardian Signature: ______________________
Date: __________
Home Telephone: _____________________
Emergency Telephone Number(s )/ Names of Contact: __________________________________________________________
This form may be duplicated or changed
to suit your needs and your patients’ needs.
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