Asthma Action Card Form
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STHMA
CTION
ARD
Name
_______________________________ Birthdate ______________________ Teacher _______________________
School Nurse _________________________________ Phone __________________ Fax __________________________
Healthcare Provider treating student for Asthma ______________________________ Phone _______________________
Preferred Hospital_____________________________ Personal Best Peak Flow Reading ____________________________
Green Zone: All Clear
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Breathing is easy. No asthma symptoms with activity or rest.
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Peak Flow Range: ________ to ________ (80%-100% of personal best) If applicable.
Pre-medicate if needed 10-20 minutes before sports, exercise or other strenuous activity.
Pre-exercise medications listed in #1 below.
Yellow Zone: Caution
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Cough or wheeze. Chest is tight. Short of breath.
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Peak Flow Range: ________ to ________ (50%-80% of personal best) If applicable.
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Medicate with quick reliever. Give medications as listed below.
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May re-check peak flow in 15-20 minutes.
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Student should respond to treatment in 15-20 minutes and return to Green Zone, if not, contact parent.
Red Zone: Emergency Plan
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Call EM-911 if student has any of the following:
Coughs constantly
No improvement 15-20 minutes after initial treatment with medication
Hard time breathing with some or all of these symptoms of respiratory distress:
Chest and neck pulled in with breathing
Stooped body posture
Struggling or gasping
Trouble with waling or talking due to shortness of breath
Lips or fingernails are grey or blue
Peak flow below ______________ (50% of personal best) If applicable.
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Medicate with quick reliever. Give medications as listed below.
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Re-check Peak Flow in 15-20 minutes.
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Student should respond to treatment in 15-20 minutes.
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Contact parent or guardian.
E
A
M
MERGENCY
STHMA
EDICATIONS
—To be completed by Healthcare Provider
1. Med _________________________________________________ Dose ________________________________
2. Med _________________________________________________ Dose ________________________________
Authorization by Healthcare Provider:
This child has received instruction in the proper use of his/her asthma medications.
It is my professional opinion that this student should/should not (Circle One) be allowed to carry, store, and use his/her
asthma medications by him/herself.
Healthcare Provider Signature: __________________________________________ Date ____________________
Anchorage School District, Nursing & Health Services
Page 1 of 2
NUR # 0505
Revised 6/2013
Created by Asthma and Allergy Foundation of America, Alaska Chapter and the Alaska Asthma Coalition, October 2005.
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