Asthma Action Plan, Child

Patient Name: Date: ________

Follow up appointment with physician:

  • Physician Name: ____________________

  • Telephone: ____________________

  • Follow-up recommendation: ____________________

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 IS UNDER CONTROL

Symptoms: Almost none; no cough or wheezing, sleeps through the night, breathing is good, can work or play without coughing or wheezing.

Use these medicine(s) EVERY DAY:

  • Controller and Dose:

  • Controller and Dose:

  • Before exercise, use a reliever medicine: ____________________

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

WHEN NOT WELL: ASTHMA IS GETTING WORSE

Symptoms: Waking from sleep, worsening at the first sign of a cold, cough, mild wheeze, tight chest, coughing at night, symptoms that interfere with exercise, exposure to known triggers (such as weather or allergies).

Add the following medicine to those used daily:

  • Reliever medicine and Dose: ____________________

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

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

Symptoms: Breathing is hard and fast, nose opens wide, ribs show, blue lips, trouble walking and talking, reliever medication (usually albuterol) not helping in 15-20 minutes, neck muscles used to breathe, if you or your child are frightened.

  • Call 911.

  • Reliever/rescue medicine:

  • Start a nebulizer treatment or give puffs from a metered dose inhaler with a spacer.

  • Repeat this every 5-10 minutes until help arrives.

Bring your medications/devices with you to your follow-up visit.

SCHOOL PERMISSION SLIP

Date: ________

Student may use rescue medication (albuterol) at school.

Parent Signature: __________________________ Physician Signature: ____________________________

Form courtesy of Arnold Palmer Hospital for Children, Orlando, Florida.