Asthma Action Plan Sheet - 2007 Page 2
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2The GREEN ZONE means take the following medicine(s) every day.
Controller Medicine(s):
Dose:
Green Zone:
“Go! All Clear!”
______________________________________________________________
Breathing is easy
______________________________________________________________
Can play, work, & sleep without
______________________________________________________________
asthma symptoms
Spacer used: ___________________________________________________
Peak Flow Range
(80%-100% of personal best)
Take the following medicine if needed 10-20 minutes before sports,
exercise, or any other strenuous activity.
_____ to _____
______________________________________________________________
The YELLOW ZONE means keep taking your Green Zone controller medicine(s)
Yellow Zone:
every day and add the following medicine(s) to help keep the asthma symptoms
“Caution…”
from getting worse.
Wake up at night
Reliever Medicine(s):
Dose:
Cough or wheeze
Chest is tight
______________________________________________________________
______________________________________________________________
Peak Flow Range
(80%-100% of personal best)
If beginning cold symptoms, call your doctor before starting oral steroids
_____ to _____
______________________________________________________________
Use Quick Reliever 2-4 puffs every 20 minutes for up to 1 hour, or use nebulizer once. If your symptoms are not better or
you do not return to the GREEN ZONE after 1 hour, follow RED ZONE instructions. If you are in the Yellow zone for more
than 12-24 hours, call your provider. If your breathing symptoms get worse, call your provider.
Red Zone:
“STOP! Medical Alert!”
The RED ZONE means start taking your Red Zone medicine(s), and call your
doctor NOW! Take these medicine(s) until you talk with your doctor. If your
Medicine is not helping
symptoms do not get better and you can’t reach your doctor, go to the emergency
Nose opens wide to breathe
room or call 911 immediately.
Breathing is hard & fast
Trouble walking
Reliever Medicine(s):
Dose:
Trouble talking
Ribs show
______________________________________________________________
______________________________________________________________
Peak Flow Range
(80%-100% of personal best)
___________________________________________________
_____ to _____
I give my permission for this Asthma Action Plan to be used by the following, and for them to share information with each
other about my student’s asthma for the current school year, so that they can work together to help my student manage
his/her asthma. This plan, when signed and dated, may replace/supplement the school’s previous asthma form, and
allows my student’s medicine(s) to be administered at school. (Check and list all that apply)
___ School/school Health Office: _____________________
___ Clinic/hospital: _________________________________
___ Daycare provider: ______________________________
___ Coach: _______________________________________
___ Teacher: _____________________________________
___ Student is allowed to carry & self-administer medications after approval of school nurse
Parent Signature ______________________________________________________ Date _____________________
MD/NP/PA Signature ___________________________________________________ Date _____________________
Revised Date: 01/18/2007
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