HealthSheets™


Asthma Action Plan for Your Child

Your child's name:

Today's date:

Next appt (date/time):

__________________________

__________________________

__________________________

Emergency contact:

Phone:

Phone:

__________________________

__________________________

__________________________

Healthcare provider:

Signature:

Phone:

__________________________

__________________________

__________________________

 

Green zone (GO zone)

My child's symptoms

What I should do

My child's medicines

  • No wheezing, coughing, or chest tightness

  • Asthma is not bothering your child's sleep, work, or school

  • Your child rarely or never uses his or her quick-relief medicine

Peak flow is:

__________________________

80% to 100% of personal best

  • Have your child keep taking long-term  controller medicines, preventive medicines, or both

  • Call your child's healthcare provider if the medicines are not controlling your child's asthma

Keep your child away from his or her asthma triggers (list):

__________________________

__________________________

__________________________

__________________________

__________________________

__________________________

 

Special instructions (before exercise, field trips, or outdoor activities):

___________________________

___________________________

 

Name:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

Name:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

 

 

 

Yellow zone (CAUTION zone)

My child's symptoms

What I should do

My child's medicines

  • Mild wheezing, coughing during day and night, or chest tightness

  • When at rest, your child's breathing is a little faster than normal

  • Asthma symptoms wake your child up at night

Peak flow is:

__________________________

50% to 80% of personal best, or
has lessened by at least 15%

Your child begins to have symptoms of a respiratory infection or a cold, if infections trigger your symptoms

  • Have your child keep taking long-term controller medicines, preventive medicines, or both

  • Give your child his or her quick-relief medicine

  • Follow the healthcare provider's instructions if your child does not feel better within an hour after using the quick-relief medicine

  • Call your child's healthcare provider right away if you are unsure of what to do

Long-term controllers:

Name:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

Special instructions:

__________________________

 

Name:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

How often:

__________________________

Special instructions:

__________________________

 

Quick-relief medicine:

Name:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

 

If your child's symptoms don't go away after 1 hour, give your child:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

 

Red zone (DANGER)

My child's symptoms

What I should do

My child's medicines

  • Continuous wheezing, coughing, or trouble breathing

  • Nostrils open in and out (flare) or ribs show when your child breathes in

  • Trouble walking or talking

  • Asthma symptoms make it hard for your child to sleep

Peak flow is:

__________________________

Less than 50% of personal best

  • Have your child use quick-relief medicines

  • Call your child's healthcare provider right away if medicines don't help your child breathe better

Call 911 if:

  • It's hard for your child to breathe, walk, or talk

  • Your child's lips or fingers look pale, gray, or blue

  • Your child feels confused, lightheaded, or dizzy

  • Your child has tightness in his or her throat or chest

Quick-relief medicine:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

 

Quick-relief medicine:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

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