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My Asthma Action Plan

Instructions: Use this Asthma Action Plan to make sure you know what to do if you develop asthma symptoms. Make sure your plan is always up-to-date.

  1. Make a few copies of this blank action plan.

  2. Save the original one and take a copy to your next office visit.

  3. Ask your healthcare provider to help you complete it.

  4. Take a new blank copy and the completed plan to each visit.

  5. If there are any changes, ask your healthcare provider to help you complete the new copy. If there are no changes, continue using the completed plan.

Your name:

_________________________

Emergency contact:

_________________________

Healthcare provider:

_________________________

Today's date:

_________________________

Phone:

_________________________

Signature:

_________________________

Next appt (date/time):

_________________________

Phone:

_________________________

Phone:

_________________________

 

Green zone (GO zone)

My symptoms

What I should do

My medicines

  • No wheezing, coughing, or chest tightness

  • Asthma is not bothering your sleep, work, or school

  • You rarely or never use your quick-relief medicine

Peak flow is:

 

_____________________

80%-100% of personal best

  • Keep taking long-term controller medicines, preventive medicines, or both

  • Call your healthcare provider if your medicines are not controlling your asthma

Stay away from your asthma triggers (list):

__________________________

 

__________________________

 

__________________________

 

__________________________

 

__________________________

 

 

Special instructions (before exercise, field trips, or outdoor activities):

 

___________________________

 

___________________________

Name:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

Name:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

 

Yellow zone (CAUTION zone)

My symptoms

What I should do

My medicines

  • Mild wheezing, coughing during day and night, or chest tightness

  • When at rest, your breathing is a little faster than normal

  • Asthma symptoms wake you up at night

Peak flow is:

 

___________________________

50%-80% of personal best, or
has lessened by at least 15%

 

You begin to have symptoms of a respiratory infection or a cold, if infections trigger your symptoms

  • Keep taking  long-term controller medicines, preventive medicines, or both

  • Use your quick-relief medicine

  • Follow your healthcare provider's instructions if you don't feel better within an hour after using your quick-relief medicine

  • Call your healthcare provider right away if you are unsure of what to do

Long-term controllers:

 

Name:

_________________________

Dose and how taken:

_________________________

How often and when:

_________________________

Special instructions:

_________________________

 

Name:

_________________________

Dose and how taken:

_________________________

How often and when:

_________________________

Special instructions:

_________________________

 

Quick-relief medicine:

 

Name:

_________________________

Dose and how taken:

_________________________

How often and when:

_________________________

 

If your symptoms don't go away after 1 hour, take:

_________________________

Dose and how taken:

_________________________

How often and when:

_________________________

 

Red zone (DANGER zone)

My symptoms

What I should do

My medicines

  • Continuous wheezing, coughing, or trouble breathing

  • Trouble walking or talking

  • Asthma symptoms make it hard for you to sleep

 

Peak flow is:

 

__________________________

Less than 50% of personal best

  • Use your quick-relief medicines

  • Call your healthcare provider right away if these medicines don't help you breathe better

 

Call 911 if:

  • It's hard to breathe, walk, or talk

  • Your lips or fingers look pale, gray, or blue

  • You feel confused, lightheaded, or dizzy

  • You have tightness in your throat or chest

Quick-relief medicine:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

 

Quick-relief medicine:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

 

Quick-relief medicine:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

 

Online Medical Reviewer: Blaivas, Allen J., DO
Online Medical Reviewer: Fraser, Marianne, MSN, RN
Date Last Reviewed: 11/1/2016
© 2000-2018 The StayWell Company, LLC. 800 Township Line Road, Yardley, PA 19067. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.