M
D
ARYLAND
EPARTMENT OF
H
EALTH AND
M
H
ENTAL
YGIENE
A
A
P
STHMA
CTION
LAN
Check Asthma Severity: Mild Intermittent
Mild Persistent
Moderate Persistent
Severe Persistent
Personal Best Peak Flow: _____
Patient’s Name
DOB
Effective Date
Personal Peak Flow Ranges
___/___/___ to ___/___/___
RED means Danger Zone!
--
Doctor’s Name
Parent/ Guardian’s Name
Get help from a doctor.
YELLOW means Caution
--
Doctor’s Office Phone Number
Parent/ Guardian’s Phone Number
Zone! Add prescribed yellow
medicine.
Emergency Contact after Parent
Contact Phone
GREEN means Go Zone!
--
Use preventive medicine.
→
Trigger List:
GO (Green)
Use these medications every day.
Chalk dust
You have all of these:
Cigarette
•
And/ or
Medicine/ Dosage
How much
When to take it
Breathing is good.
smoke
personal
to take
•
No cough or wheeze.
Colds/Flu
peak flow
•
Sleep through the
above
Dust or dust
80 %
night.
mites
•
Stuffed
Can work and play.
Comments
animals
Carpet
For exercise, take:
Exercise
Mold
Ozone alert
→
CAUTION (Yellow)
Continue with green zone medicine and ADD:
days
Pests
You have any of these:
And/ or
Medicine/ Dosage
How much
When to take it
Pets
•
personal
to take
First sign of a cold.
Plants,
peak flow
•
Exposure to a known
flowers, cut
from
trigger.
80%
grass, pollen
•
Cough.
Strong
Comments
•
Mild wheeze.
odors,
To
•
Tight chest.
perfume,
50%
•
Cough at night.
cleaning
If Quick Reliever/ Yellow Zone medicines are used more than
products
2 to 3 times per week, CALL your Doctor.
Sudden
→
temperature
DANGER (Red)
Take these medicines and call your doctor.
change
Wood
Your asthma is getting worse fast:
Medicine/ Dosage
How much
When to take it
smoke
•
Medicine is not helping
to take
Foods:
within 15-20 minutes.
And/ or
____________
•
Breathing is hard and
personal
fast.
peak flow
•
below
Nose opens wide.
Comments
Other:
50%
•
Ribs show.
•
Lips are blue.
GET HELP FROM A DOCTOR NOW!
•
Fingernails are blue.
If you cannot contact your doctor, go directly to the emergency room.
•
Trouble walking or talking.
DO NOT WAIT.
Adapted from: NYC DOHMH and Pediatric/ Adult Asthma Coalition of New Jersey.
White Copy- Patient
Pink Copy- School
Yellow Copy- Doctor
DHMH Form Number: 4643
For additional forms, please call: 410-799-1940