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.

  • My shortness of breath is getting worse even when I am   using my medicines properly.

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: ____________

Request a Refill

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