ASTHMA ACTION PLAN
asthma_action_plan_barcode

Attach Patient Sticker Here/Above

Your Health Care Provider's Name  Your Health Care Provider's Phone: 
Your Predicted Peak Flow:                                                                 Your Personal Best:                     

Green Light  GREEN ZONE

   GO! 

    
 BREATHING IS GOOD


green_dotNo cough or wheeze
green_dotCan play and sleep
green_dot

 CONTROLLER    MEDICATION                STRENGTH           AMOUNT              TIMES / DAY

times / day
Gargle, rinse mouth, and spit after each dose
  times / day
  times / day
times / day
- Always use a spacer or holding chamber with MDI.
Use Reliever 10-15 minutes before exercise

Yellow Light  YELLOW ZONE

SLOW DOWN!

 HAVING TROUBLE  BREATHING


green_dotCoughing and wheezing
green_dotChest tight
green_dotWake up at night
green_dot


 

 RELIEVER  MEDICATION                       STRENGTH         AMOUNT           TIMES / DAY 
OR
- Recheck symptoms 15 minutes after taking reliever. Advance to red zone if not improving.
 CONTINUE YOUR CONTROLLER
  times / day
Gargle, rinse mouth, and spit after each dose
  times / day
  times / day
times / day
 - If not back in the Green Zone in 48 hours, call your Health Care Provider.
 - No outside activities on high ozone days.
Red Light   RED ZONE

    STOP!!!   

 ASTHMA IS OUT OF  CONTROL

red_dotIncreased yellow zone symptoms
red_dotReliever medicine isn't working
red_dot Breathing hard and fast
green_dot Can't walk or talk well
green_dot Can't sleep
green_dot

 RELIEVER  MEDICATION                       STRENGTH          AMOUNT           TIMES / DAY
OR
- While taking your reliever medicine, call your Health Care Provider for advice or go to the Emergency Room.

DANGER! Follow these steps:
 - *For skin color changes or blue lips, call 911.
 - *If still in the Red Zone after 3 treatments or if not better, call 911. 
 - *Call your Health Care Provider whenever taking Red Zone Medicines.

 Special Instructions

                                                                                  

CHILDREN'S MEDICAL CENTER DALLAS 1935 Medical District Drive - Dallas, Texas 75235 (214) 456-7000