My Asthma Action Plan

My Asthma Action Plan

Fill in this asthma action plan. This is so you know what to do if you have asthma symptoms. Make sure your plan is always up-to-date.

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

  2. Take a copy to your next healthcare visit.

  3. Ask your healthcare provider to help you fill it in.

  4. Bring the completed plan and a new blank one to each visit.

  5. If there are any changes, ask your healthcare provider to help you fill in the new copy. If there are no changes, keep using your current 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 them here):

__________________________

__________________________

__________________________

__________________________

__________________________

Special instructions (such as before exercise, field trips, or outdoor activity):

___________________________

___________________________

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 day and night, or chest tightness

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

  • Asthma symptoms wake you up at night

  • You begin to have a respiratory infection or a cold (if this has triggered your symptoms in the past)

Peak flow is:

___________________________

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

 

  • 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 1 hour of 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
  • Ongoing 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 don't help you breathe.

CALL 911 if

  • It's hard for you 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: Alan J Blaivas DO

Online Medical Reviewer: Amy Finke RN BSN

Online Medical Reviewer: Daphne Pierce-Smith RN MSN CCRC

Date Last Reviewed: 9/1/2018

© 2000-2019 StayWell, 780 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.