Print out this action plan (PDF page 1, PDF page 2) and use to monitor you asthma. Bring it with you to your doctor appointments -- this information will be very useful in assisting him/her to assess your condition.
Date : ______
My Personal Best Peak Flow __________
| Doing Well | |||
| Symptoms
No/minimal/few symptoms such as cough, wheeze, chest tightness or shortness of breath No limitations in usual activities. My usual medicines control my asthma. |
Green Zone
Peak flow: _____to_____ (80-100% of my personal best peak flow.) |
||
| When I am doing well, I should follow my daily treatment plan: | |||
| Medicine | Dose | Maximum number of times/day and duration | |
| Reliever: | |||
| Preventer : | |||
| Other : | |||
| Caution | |||
| Symptoms
Presence or increase of such symptoms as cough, wheeze, chest tightness or shortness of breath (including symptoms at night.) Limitations in your ability to perform usual activities. Increased need for asthma (reliever) medicine |
Yellow Zone
Peak flow: _____to_____ (50-80% of my personal best peak flow.) |
||
| When I am in the caution/yellow zone, I should adjust my current medicines and/or add medicines as indicated below: | |||
| Medicine | Dose | Maximum number of times/day and duration | |
| Reliever: | |||
| Preventer : | |||
| Other : | |||
| Caution | |||
| Symptoms
Extreme cough, wheeze, chest tightness or shortness of breath (including symptoms at night.) Cannot perform usual activities. Symptoms are the same or worse after 24 hours in the CAUTION/Yellow zone. Asthma medicines have not reduced symptoms. |
Yellow Zone
Peak flow: _____to_____ (Less than 50% of my personal best peak flow.) |
||
| When I am in the medical alert/red zone, I should adjust my current medicines and/or add medicines as indicated below: | |||
| Medicine | Dose | Maximum number of times/day and duration | |
| Reliever: | |||
| Preventer : | |||
| Other : | |||
| I should call the doctor immediately when : |
My reliever medicine is not helping my symptoms as well as it should.
|
| I need to go to the hospital now or call 911 now if : |
| My reliever drug is not working.
I suddenly feel faint or frightened. I have difficulty talking due to shortness of breath. My lips or fingernails are blue. child with asthma is having a hard time breathing and is hunched over and/or struggling to breathe. |
| WHEN IN DOUBT, GO TO THE HOSPITAL. |
Emergency Telephone Numbers:
Emergency Help Line: 911 or other ____________
Nearest Emergency Room: ____________
Ambulance: ____________
My Doctor: ____________
