Asthma Action Plan
For School or Child Care

Name: _________________________________________		Date of Birth: ____________________
Parent/Guardian Name:____________________________		Phone: __________________________
Parent/Guardian Name:____________________________		Phone: __________________________
Emergency Contact (1):	________________________	___________________	_____________
	Name	Relationship	Phone
Emergency Contact (2):	________________________	___________________	_____________
	Name	Relationship	Phone
Physician Name: ________________________________		Phone: __________________________
Other Physician: ________________________________		Phone: __________________________

Asthma Triggers - Identified items which may cause asthma attacks (circle all that apply):

dust mites	strong odors	tobacco smoke	colds/infections
mold	mice/rats	exercise	temperature change
pets	pollen	chalk dust	excitement
cockroach	dust	smoke (other than tobacco)	pesticides
food (specify):_________________________________________________________________
other (specify):_________________________________________________________________

Activities - that have caused asthma attacks in the past (circle all that apply):

art projects with dust or fumes	playing outdoors on cold/windy days
sitting on carpeting	playing in freshly cut grass
pet care	gardening
wood/kerosene heated rooms	running hard
other (specify):____________________________________________________________________

Peak Flow Monitoring

Personal best peak flow reading:_______________________________________________________

Reading to give quick-relief medication:__________________________________________________

Reading to get medical help:___________________________________________________________

Typical Signs and Symptoms - of asthma attacks (circle all that apply):

persistent cough	flaring nostrils/panting	dark circles under eyes
wheezing	breathing faster	gray or blue lips/fingernails
shortness of breath	grunting	sucking in chest/neck
restlessness	fatigue	trouble talking/walking

Reminders:

1. Notify parents immediately if emergency medication is required.

2. Seek emergency medical care if:

   • there are no improvements 15-20 minutes after initial treatment with mediation and family can not be reached

   • after receiving treatment for asthma symptoms, the child has

     • chest / neck pulled in with breathing	• gray or blue lips / fingernails
     • trouble talking / walking	• hunched over

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	Asthma Action Plan
For School or Child Care

Condition		Medications and Action Steps
G R E E N Z O N E	All Clear No asthma symptoms Able to do usual activities Peak Flow Reading ____________________ (80% or more of best) Good Control	Medicine Amount (dose) When                         Quick Relief Medicine should not be needed except before exercise and exposure to a known trigger   Before exercise and exposure to a known trigger take: _______________________________________________ (15 minutes before exercise or exposure)
Y E L L O W Z O N E	Asthma Symptoms   Coughing, wheezing, tightness in chest, shortness in breath Usual activities somewhat limited Peak Flow Reading ______ to______ (50-80% of best) Caution	Continue taking Green Zone Medicines and ADD: Medicine Amount (dose) When             If symptoms persist after one hour or worsen add:             Continue with Yellow Zone action for ______ hours   Call physician within ______ hours   Notify parent and physician when oral steroids are used
R E D Z O N E	Danger! Very short of breath, trouble walking / talking Usual activities severely limited Quick-relief medication has not helped Peak Flow Reading ________________ (50% of best) Medial Alert!!	Continue taking Yellow Zone Medicines and ADD: Medicine Amount (dose) When             Start oral steroids if not already Medicine Amount (dose) When       Call physician right away! If symptoms do not improve within 15 minutes and physician can not be reached - go to the hospital or call 911 right away
Danger Signs	*Difficulty walking / talking from shortness of breath >>> *Bluish / grayish color to palms or lower inner eyelid >>> Go to the hospital now Or call 911

Physician’s Signature:_________________________________________	Date:____________________
Parent / Guardian Signature:____________________________________	Date:____________________

*Based on the National Heart, Lung, and Blood Institute’s “Guidelines for the Diagnosis and Management of Asthma” 1997