Asthma Action Plan Form - Virginia Asthma Coalition (Vac) printable pdf download

Virginia Asthma Action Plan

School Division: ________________________________________________________________________

Name

Date of Birth

Effective Dates

Health Care Provider

Provider’s Phone #

Fax #

Last flu shot

Parent/Guardian

Parent/Guardian Phone

Parent/Guardian Email:

Additional Emergency Contact

Contact Phone

Contact Email

Asthma Severity:

Intermittent or Persistent:  Mild  Moderate  Severe

Asthma Triggers (Things that make your asthma worse)

□

_________________

Colds

Smoke (tobacco, incense)

Pollen

Dust

Animals:

Strong odors

Mold/moisture

Stress/Emotions

□

______________________

Exercise

Acid reflux

Pests (rodents, cockroaches)

Season (circle): Fall, Winter, Spring, Summer

Other:

Green Zone: Go! —

Take these CONTROL (PREVENTION) Medicines EVERY Day

Always rinse your mouth after using your inhaler and remember to use a spacer with

You have ALL of these:

your MDI.

 No control medicines required.



Breathing is easy

Dulera ______ Symbicort ______  Advair ______ , ____ puff (s) ____ times a day



No cough or wheeze

Combination medications: inhaled corticosteroid with long-acting -agonist



Can work and play

 Alvesco _____ Asmanex ____  Azmacort _____  Flovent ____ Pulmicort  QVAR

____



Inhaled Corticosteroid or Inhaled corticosteroid/long-acting -agonist

Can sleep all night

____ puff (s)

___

Or ____

___

MDI

times a day

nebulizer treatment (s)

times a day

Peak flow: _______ to _______

 Singulair or __________________________, take ____ by mouth once daily at bedtime

(More than 80% of Personal Best)

Leukotriene antagonist

Personal best peak flow:________

 Albuterol or ____________________, _____ puffs with

For asthma with exercise, ADD:

spacer 15 minutes before exercise

Yellow Zone: Caution!

— Continue CONTROL Medicines and ADD

RESCUE

Medicines

You have ANY of these:

 Albuterol or __________________, ____ puffs with spacer every ____ hours as needed



Inhaled -agonist

Cough or mild wheeze

 Albuterol or _________________, one nebulizer treatment (s) every ____ hours as needed



First sign of cold

Inhaled agonist



Tight chest



Problems sleeping,

Call your Healthcare Provider if you need rescue medicine for more than 24

working, or playing

hours or two times a week, or if your rescue medicine doesn’t work.

Peak flow: _______ to ______

(60% - 80% of Personal Best)

Red Zone:

DANGER!

—

Red Zone:

DANGER!

—

Continue CONTROL & RESCUE Medicines and

GET HELP!

Continue CONTROL & RESCUE Medicines and

GET HELP!

You have ANY of these:

 Albuterol or ______________, __ puffs with spacer every 15 minutes, for THREE treatments

Inhaled -agonist



Can’t talk, eat, or walk well

 Albuterol or ____________, one nebulizer treatment every 15 minutes, for THREE



treatments

Medicine is not helping

Inhaled -agonist



Breathing hard and fast

Call your doctor while administering the treatments.



Blue lips and fingernails

IF YOU CANNOT CONTACT YOUR DOCTOR:



Tired or lethargic

Call 911 or go directly to the



Ribs show

Emergency Department NOW!

Peak flow: < _______

(Less than 60% of Personal Best)

EQUIRED

IGNATURES

SCHOOL MEDICATION CONSENT & HEALTH CARE PROVIDER ORDER

I give permission for school personnel to follow this plan, administer medication

HECK ALL THAT APPLY

and care for my child and contact my provider if necessary. I assume full

responsibility for providing the school with prescribed medication and delivery/

____

Student instructed in proper use of their asthma medications, and in my

monitoring devices. I approve this Asthma Management Plan for my child.

opinion, CAN CARRY AND SELF-ADMINISTER INHALER AT SCHOOL.

_____________________________

Date ________

____

Student is to notify designated school health officials after using

ARENT

UARDIAN

inhaler at school.

________________________

Date ________

CHOOL

URSE

ESIGNEE

____

Student needs supervision or assistance to use inhaler.

______________________________________

Date ________

THER

____

Student should NOT carry inhaler while at school.

CC:

  Principal  Cafeteria Mgr  Bus Driver/Transportation

____________________________

_______

IGNATURE

ATE

   Coach/PE  Office Staff

 School Staff

Blank copies of this form may be reproduced or downloaded from

Virginia Asthma Action Plan approved by the Virginia Asthma Coalition (VAC) 4/11

Based on NAEPP Guidelines and modified with permission from the D.C. Asthma Action Plan via District of Columbia

Department of Health, DC Control Asthma Now, and District of Columbia Asthma Partnership

Asthma Action Plan Form - Virginia Asthma Coalition (Vac)

Related Articles

Related forms

Related Categories