Asthma Action Plan

Asthma Action Plan

Patient Name: [Patient name]

Date of Birth: [Date of birth]

Plan Date: [Creation date]

Last Updated: [Last updated date]

Clinician: [Clinician name, credentials, clinic]

Clinic Phone: [Clinic phone number] (If not provided, display __________)

After-Hours/Emergency Contact: [After-hours contact number] (If not provided, display __________)

Monitoring & Reliever Strategy

Monitoring method: [Symptoms only / Symptoms + Peak flow]

Personal best peak flow: [Personal best value] L/min (Include only if using peak flow monitoring. If not yet established, state: "Not yet established — use symptom-based zones only.")

• Green Zone: ≥ [value] L/min (≥80% of personal best)
• Yellow Zone: [lower value] – [upper value] L/min (50–79% of personal best)
• Red Zone: < [value] L/min (<50% of personal best)

(Include peak flow thresholds only if using peak flow monitoring and personal best is established.)

Reliever strategy: [SABA reliever / ICS-formoterol reliever (MART/SMART) / ICS-SABA combination] (Select one strategy only.)

Reliever medication: [Medication name, device/form, strength, dose instructions]

Green Zone – Doing Well

Criteria:

• No cough, wheeze, chest tightness, or shortness of breath
• Sleeping well with no nighttime symptoms
• Able to do usual activities
• Peak flow ≥ [Green threshold] L/min (Include only if using peak flow)

Daily controller medications:

• [Controller medication: name, device/form, strength, dose, frequency]

(Add additional medications as needed. If no controller is prescribed, state: "No daily controller medication prescribed.")

Before exercise: [Pre-exercise medication and instructions] (Include only if prescribed.)

Yellow Zone – Getting Worse

Criteria:

• Worsening cough, wheeze, chest tightness, or trouble breathing
• Night waking due to asthma
• Some activity limitation
• Peak flow [Yellow lower] – [Yellow upper] L/min (Include only if using peak flow)

Actions:

1. Continue all daily controller medications. Use reliever now: [Reliever name], [dose], repeat every [interval] as needed, up to [maximum per 24 hours].
2. Reassess symptoms in [timeframe, typically 1 hour]. If back to Green, continue usual monitoring. If not improving, proceed to Step 3.
3. [Oral corticosteroid instructions: medication, dose, frequency, duration] (Include only if explicitly authorized by clinician with patient-specific dosing. If not authorized, state: "Do not start oral steroids unless prescribed and instructed by your clinician.") Call your clinician if you need the reliever more often than every [interval] hours or if symptoms are not improving.

Red Zone – Medical Alert

Criteria:

• Severe breathing difficulty
• Reliever not helping or relief not lasting
• Unable to do usual activities
• Not improving after following Yellow Zone steps
• Peak flow < [Red threshold] L/min (Include only if using peak flow)

Immediate actions:

• Take reliever now: [Reliever name], [dose], repeat every [interval] as needed.
• Take oral corticosteroid now: [Medication, dose] (Include only if part of this patient's authorized plan.)
• Call your clinician immediately.

EMERGENCY RULE: If not improving within 15 minutes, or you cannot reach your clinician, call 911 or go to the emergency room now.

Danger signs — call 911 now:

• Trouble walking or talking due to shortness of breath
• Lips or fingernails turning blue, gray, or pale

My Triggers

(Check all that apply.)

• ☐ Pollen
• ☐ Air quality/pollution
• ☐ Cold air
• ☐ Dust mites
• ☐ Pets
• ☐ Mold
• ☐ Tobacco smoke/vaping
• ☐ Strong odors
• ☐ Viral illness
• ☐ Exercise
• ☐ Stress
• ☐ Other: [Other triggers]

Top triggers for me: [Identified triggers, separated by semicolons] (Include only those identified.)

(Omit any sections or fields for which information is not provided, except phone numbers which should display placeholder lines. Use plain language throughout.)