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