Asthma Action Plan, Adult

Patient Name: __________________________________________________ Date: ________

Follow-up appointment with physician:

  • Physician Name: ____________________

  • Telephone: ____________________

  • Follow-up recommendation: ____________________

Always bring all of your medications to all of your appointments.

POSSIBLE TRIGGERS

Tobacco smoke, dust mites, molds, pets, cockroaches, strong odors and sprays (burning wood in fireplace, incense, scented candles, perfume, paints, cleaning products), exercise, pollen, cold air, or the flu.

WHEN WELL: ASTHMA UNDER CONTROL

Symptoms: No cough or wheezing, chest tightness or shortness of breath either during the day or at night; can participate in usual activities.

If using a peak flow meter:

My optimal peak flow is: _____ to _____ (should be 80-100% of personal best)

Medicine(s):

Every day:

  • Controller: ________________ How much? ________________ When? ________________

  • Controller: ________________ How much? ________________ When? ________________

Before exercise:

  • Reliever: ________________ How much? ________________ When? ________________

If symptoms are noted:

  • Reliever/Rescue: ________________ How much? ________________ When? ________________

Call your physician if using reliever more than 2-3 times per week.

WHEN NOT WELL: ASTHMA GETTING WORSE

Symptoms: Cough, wheeze, shortness of breath, chest tightness, waking at night due to asthma, unable to participate in all of usual activities.

If using a peak flow meter:

My peak flow is: _____ to _____ (50-79% of personal best)

Add the following medicine to those used daily:

  • Reliever/Rescue: ________________ How much? ________________ When? ________________

If symptoms and peak flow return to GREEN ZONE after 1 hour of above treatment, continue monitoring to make sure you remain in green zone.

If symptoms and peak flow DO NOT return to GREEN ZONE after 1 hour of above treatment:

  • Reliever/Rescue: ________________ How much? ________________ When? ________________

  • Oral Steroids: ________________ How much? ________________ When? ________________

  • Call your doctor if: ________________________________________________________________

IF SYMPTOMS GET WORSE: ASTHMA IS SEVERE - GET HELP NOW!

Symptoms: Severely short of breath, rescue meds have not helped, cannot participate in usual activities, you are having trouble walking or talking due to asthma symptoms, you are dizzy or faint, your fingernails or lips are bluish, your symptoms are the same or worse after 24 hours in Yellow Caution Zone.

If using a peak flow meter:

My peak flow is: less than _____ (50% of personal best)

Add the following medicine to those used daily:

  • Reliever/Rescue: ________________ How much? ________________ When? ________________

  • Oral Steroids: ________________ How much? ________________ When? ________________

  • CALL YOUR DOCTOR IMMEDIATELY.

Have someone drive you to the hospital right away or call your local emergency services (911 in U.S.) if you are in the red danger zone after 15 minutes and you have not reached your doctor.