Student Asthma Action Card
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Name: _____________________________________________ D.O.B. _____________ Teacher _____________
School Nurse: ____________________________________ Phone Number: ______________________________
ID Photo
Health Care Provider Treating Student for Asthma: _____________________________ Ph: _________________
Preferred Hospital________________________________________________________
My Personal Best Peak Flow Reading: _____________________ (If Applicable)
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 to 100% of personal best) if applicable.
□ Pre-medicate if needed 10 to 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 to 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 to 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 EMS 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 walking 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 to 20 minutes.
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Student should respond to treatment in 15-20 minutes.
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Contact parent/guardian.
Emergency Asthma Medications
-to be completed by Health Care Provider
1. Med_________________________________________________________________Dose___________________________________
2. Med_________________________________________________________________ Dose___________________________________
3. Epinephrine Autoinjector will be used in the event of a severe asthma episode at school. This may be given in addition to the
student’s prescribed medication or if student does not have access to his/her prescribed medication.
Dosage_____0.3mg OR ______0.15mg
Health Care Provider AUTHORIZATION:
□ 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.
Health Care Provider Signature: __________________________________________Date: ________________
Created by Asthma and Allergy Foundation of America, Alaska Chapter and the Alaska Asthma Coalition, October 2005. Revised 2012
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