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My Asthma Action Plan
Overview
- My name ______________________________________
- Doctor's name _________________________________
- Doctor's phone ________________________________
| Controller medicine | How much? | How often? | Other instructions |
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| Quick-relief medicine | How much? | How often? | Other instructions |
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Important
EMERGENCY: If it's hard to walk or talk because of shortness of breath or if your lips or fingertips are blue, CALL 911 or go to the hospital for help right away.
| GREEN ZONE This is where I want to be! | YELLOW ZONE My asthma is getting worse. | RED ZONE Danger! |
Symptoms - I have no shortness of breath, cough, wheezing, or chest tightness.
- I can do all of my usual activities.
- I sleep well at night.
| Symptoms - I'm coughing or wheezing or have chest tightness or shortness of breath.
- Symptoms keep me up at night.
- I can do some but not all of my usual activities.
| Symptoms - I'm very short of breath.
- I can't do my usual activities.
- Quick-relief medicine doesn't help, or my symptoms don't get better after 24 hours in the yellow zone.
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Peak flow (if I use a peak flow meter) - _________ or more (80% or more of my personal best)
| Peak flow (if I use a peak flow meter) - ______ to ____ (50% to 79% of my personal best)
| Peak flow (if I use a peak flow meter) - _____ or lower (less than 50% of my personal best)
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Actions - [ ] Take controller medicine(s) every day.
- [ ] Avoid asthma triggers.
- [ ] ____ minutes before exercise, take quick-relief medicine called ________________.
| Actions - [ ] Take _____ puff(s) of my quick-relief medicine called ________________. Repeat ____ times.
- [ ] If my symptoms don't get better or my peak flow has not returned to the green zone in 1 hour, then:
- [ ] Take _____ puff(s) of my medicine called ________________. Take it ___ times a day.
- [ ] Begin or increase treatment with corticosteroid pills. Take ______ mg of ________________ every _______________.
- [ ] Call my doctor at _______________.
| Actions - [ ] Take _____ puff(s) of my quick-relief medicine called _____________. Repeat _____ times.
- [ ] Begin or increase treatment with corticosteroid pills. Take ________ mg now.
- [ ] Call my doctor at ______________. If I cannot contact my doctor, I need to go to the emergency department or call for help right away.
- [ ] Other numbers I might call are ______________, ______________, ______________.
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Credits
Current as of: July 31, 2024
Current as of: July 31, 2024
