Asthma Action Plan

ADVERTISEMENT

Asthma Action Plan
To be completed by the physician and signed by both physician and parent
Effective Date:
_________ to _________
Student’s Name: _____
______________________________
Birth Date: ____________
Homeroom Teacher: _____________________________________________ Grade: _______________
Physician’s printed name _______________________________________ Phone __________________
Parent/Guardian: _____________________________________________________________________
Phone: Home____________________ Business ____________________ Cell____________________
Emergency Contact after parent: ____________________________________ Phone_______________
Asthma Severity: ___Mild Intermittent
___Mild Persistent
___Severe Persistent
Asthma Triggers: ___Colds ___Exercise
___Animals
___Dust
___Smoke
___Food
___Weather
___Other:
___________________________________________________________________________________
TAKE THESE MEDICINES EVERYDAY
(Green Zone)
Medicine:
How Much:
When To Take It:
Child feels good:
________________________________________________________________
-Breathing is good
________________________________________________________________
-No Cough or wheeze
_______________________________________________________________
-Can work/play
_______________________________________________________________
-Sleeps at night
_______________________________________________________________
20 MINUTES BEFORE EXERCISE USE THIS MEDICINE:
Peak flow in this area:
_____ to _____
_____________________
_____________________
_____________________
Name
Dosage
Route
____________________________________________________________________________________
TAKE EVERYDAY MEDICINES AND
THESE RESCUE MEDICINES
(Yellow Zone)
IF NOT FEELING WELL
Medicine:
How Much:
When To Take It:
Child has any of these:
-Cough
_______________________________________________________________________________
-Wheeze
_______________________________________________________________________________
-Tight Chest
_______________________________________________________________________________
Peak flow in this area:
Call your doctor/nurse’s office if the symptoms don’t improve in 2 days OR if the flare lasts for
_____to _____ for longer than _____ days. After _____ days go back to GREEN ZONE and take everyday
medications as instructed.
____________________________________________________________________________________________________
IF FEELING VERY SICK CALL THE DOCTOR OR NURSE NOW!
TAKE THESE MEDICINES
(Red Zone
)
Medicine:
How Much:
When To Take It:
Child has any of these:
-Medicine not helping
__________________________________________________________________________
-Breathing is hard and fast
__________________________________________________________________________
- Lips and fingernails are blue __________________________________________________________________________
-Can’t walk or talk well
__________________________________________________________________________
__________________________________________________________________________________________________
Peak flow below:
_____________
IF UNABLE TO CONTACT YOUR DOCTOR OR NURSE:
Call 911 or go to the nearest emergency room and bring this form with you!
PLEASE COMPLETE BOTH SIDES OF THIS FORM

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2