Name: ________________________________

Asthma Action Plan
Asthma Triggers
Name: ________________________________ DOB:__________
Try to stay away from or control these things:
□ Exercise □ Smoke, strong odors or spray Doctor: ______________________ Date:___________________
□ Mold □ Colds/Respiratory infections
Phone for Doctor or Clinic: _____________________________
Predicted/Personal Best Peak Flow Reading:_______________
□ Tobacco smoke □ Cockroaches □ Food ________ □ Other ____________________ Use these controller medicines every day to keep you in the green zone:
1. Green – Go
Medicine: How much to take: When to take it: □ Home _________________________________________________________________ _________________________________________________________________ Or Peak Flow ______ to ______ (80-100%) 5-15 minutes before very active exercise, use □ Albuterol ______ puffs. Keep using controller green zone medicines everyday.
2. Yellow – Caution
Add these medicines to keep an asthma attack from getting bad:
Medicine How much to take When to take it Albuterol □ 2 puffs by inhaler □ May repeat every or □ 4 puffs by inhaler 20 min up to 3 doses ________ □ with spacer, if available in first hour, if needed □ by nebulizer
If symptoms DO NOT improve after first hour of treatment, then go to red zone.
If symptoms DO improve after first hour of treatment, then continue:
Albuterol □ 2 puffs by inhaler □ Every 4 - 8 hours
or □ 4 puffs by inhaler for _______ days _________ □ with spacer, if available ______________________________, _____times a day for ______days □ Home (oral corticosteroid) (how much)
Call your doctor if still having some symptoms for more than 24 hours!
Call your doctor and/or parent/guardian NOW!
3. Red – Stop – Danger
Take these medicines until you talk with a doctor or parent/guardian:
Medicine: How much to take: When to take it: Albuterol □ 2 puffs by inhaler □ May repeat every or □ 4 puffs by inhaler 20 minutes until ________ □ with spacer, if available you get help ______________________________, _____times a day for ______days □ Home (oral corticosteroid) (how much) □ School Call 911 for severe symptoms, if symptoms don’t improve, or you can’t reach your doctor
and/or parent/guardian.
Physician Signature ______________________ Date______________ Phone__________________
WHITE – PATIENT YELLOW – CHART PINK – SCHOOL Provided by Community Care of N.C., N.C. Asthma Program, and Asthma Alliance of N.C. 10/08

Source: http://www.wilmingtonhealth.com/media/uploads/Specialties/Pediatrics/AsthmaActionPlanRecommendedSchoolAsthmaActionPlan(2)-1.pdf