My Asthma Action Plan

Symptoms

• I have no shortness of breath, cough, wheezing, or chest tightness.
• I can do all of my usual activities.
• I sleep well at night.

Symptoms

• I'm coughing or wheezing or have chest tightness or shortness of breath.
• Symptoms keep me up at night.
• I can do some but not all of my usual activities.

Symptoms

• I'm very short of breath.
• I can't do my usual activities.
• Quick-relief medicine doesn't help, or my symptoms don't get better after 24 hours in the yellow zone.

Peak flow (if I use a peak flow meter)

• _________ or more (80% or more of my personal best)

Peak flow (if I use a peak flow meter)

• ______ to ____ (50% to 79% of my personal best)

Peak flow (if I use a peak flow meter)

• _____ or lower (less than 50% of my personal best)

Actions

• [ ] Take controller medicine(s) every day.
• [ ] Avoid asthma triggers.
• [ ] ____ minutes before exercise, take quick-relief medicine called ________________.

Actions

• [ ] Take _____ puff(s) of my quick-relief medicine called ________________. Repeat ____ times.
• [ ] If my symptoms don't get better or my peak flow has not returned to the green zone in 1 hour, then:
  • [ ] Take _____ puff(s) of my medicine called ________________. Take it ___ times a day.
  • [ ] Begin or increase treatment with corticosteroid pills. Take ______ mg of ________________ every _______________.
  • [ ] Call my doctor at _______________.

Actions

• [ ] Take _____ puff(s) of my quick-relief medicine called _____________. Repeat _____ times.
• [ ] Begin or increase treatment with corticosteroid pills. Take ________ mg now.
• [ ] Call my doctor at ______________. If I cannot contact my doctor, I need to go to the emergency department or call for help right away.
• [ ] Other numbers I might call are ______________, ______________, ______________.