My Asthma Action Plan

My name:__________________ Doctor’s name: ___________________ Doctor’s phone: _______________ Controller medicine How much? How often? Other instructions Quick-relief medicine How much? How often? Other instructions GREEN ZONE This is where I want to be! YELLOW ZONE My asthma is getting worse. RED ZONE Danger! Symptoms…

My Asthma Action Plan

Topic Overview

My name:__________________

Doctor's name: ___________________

Doctor's phone: _______________

Controller medicine

How much?

How often?

Other instructions

Quick-relief medicine

How much?

How often?

Other instructions

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.

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)

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. Call 911 or _________________.
  • [ ] Other numbers I might call are ______________, ______________, ______________.

EMERGENCY: If it's hard to walk or talk because of shortness of breath or if my lips or fingertips are blue, I need to CALL 911 or go to the hospital for help right away.

Credits

Current as ofJune 9, 2019

Author: Healthwise Staff
Medical Review: E. Gregory Thompson, MD - Internal Medicine
Adam Husney, MD - Family Medicine
Rohit K. Katial, MD - Allergy and Immunology

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