Asthma Action Plan (School/Home)

Asthma Action Plan — Home and School Use

Patient Name: [full name]   |   Date of Birth: [DOB]   |   School/Grade: [school name and grade/classroom] (Include only if for school use; omit if home-only)

Plan Date: [date completed]   |   Last Reviewed: [date]   |   Clinician: [name, clinic, phone]

Contacts

Parent/Guardian: [name], [phone]
Emergency Contact: [name], [phone]
Clinician: [phone]
Emergency: Call 911

My Asthma & Medicines

Severity: [intermittent / mild persistent / moderate persistent / severe persistent / not yet determined]

My Triggers: [known triggers] (If none identified, state "Triggers not yet identified")

Peak Flow: I use a peak flow meter: [Yes / No]. Personal best: [value and units]. (If peak flow not used, state "Peak flow not used" and omit personal best)

Daily Controller Medicine: [medication name, dose, schedule, device, special instructions] (If none prescribed, state "No daily controller medicine prescribed." Never infer dose.)

Quick-Relief (Rescue) Medicine: [medication name, dose, device] | Spacer required: [Yes / No] | Location: [nurse office / self-carry / both] (Never infer dose.)

GREEN ZONE — Doing Well

(Use green visual indicator)

• I have no coughing or wheezing.
• I sleep well with no nighttime symptoms.
• I can play, learn, and exercise normally.
• My peak flow is ≥80% of my personal best: [calculated threshold] or higher. (Include only if using peak flow)

What I take every day: I take my daily controller medicine as listed above.

Before exercise: [medication, dose, timing before activity] (If not prescribed, state "No pre-exercise medicine prescribed")

YELLOW ZONE — Caution

(Use yellow visual indicator)

• I am coughing, wheezing, or my chest feels tight.
• I wake up at night with breathing problems.
• It is harder to breathe, play, or learn than usual.
• My peak flow is 50–79% of my personal best: [calculated range]. (Include only if using peak flow)

1. Take my quick-relief medicine now: [medication name and exact dose].
2. Keep taking my daily controller medicine.
3. If I am not better in [minutes], repeat my quick-relief dose (maximum [number] times in 24 hours).
4. Oral steroid: [medication, dose, duration] (If not prescribed, state "Oral steroid: Not prescribed")
5. Call my clinician if I am not improving or if I am in the YELLOW ZONE frequently.

School note: Notify my parent/guardian. Modify my activity until I am back in the GREEN ZONE.

If getting worse or not improving → Go to RED ZONE.

RED ZONE — Get Help Now

(Use red visual indicator with boxed emphasis)

• I am very short of breath or it is hard to breathe.
• I cannot speak in full sentences.
• My lips or fingernails look blue or gray.
• The skin between my ribs or at my neck pulls in when I breathe.
• My peak flow is less than 50% of my personal best: below [calculated threshold]. (Include only if using peak flow)

1. Take my quick-relief medicine NOW: [medication name and exact dose].
2. Call my clinician right away OR call 911.

DANGER SIGNS — CALL 911:

• Trouble walking or talking because of breathing.
• Lips or fingernails are blue or gray.
• Not improving after using my rescue medicine.

If I am still in the RED ZONE after 15 minutes, call 911.

Authorization

Parent/Guardian: "I authorize administration of the above medicines at school and consent to communication between my child's clinician and school health staff."
[Signature]   [Printed name]   [Date]

Prescriber: [Signature]   [Printed name]   [Date]   [Phone]

Self-Carry Authorization: "Student has demonstrated ability to carry and self-administer quick-relief medicine."
[School nurse signature]   [Date]
(Include only if explicitly authorized; never infer based on age)

Review and update at least yearly or when medicines change. Provide signed copies to parent/guardian, school nurse, and clinician.

---

Optional Device Instructions

(Include this page only if nebulizer or complex technique guidance is needed; otherwise omit entirely)

Inhaler With Spacer

[Step-by-step technique including shaking/priming, proper seal, slow deep inhalation, breath-hold, wait time between puffs, and cleaning instructions]

Nebulizer

[Medication name and unit dose for nebulizer cup, assembly and operation steps, breathing technique, duration, and cleaning/storage instructions] (Never infer medication doses)