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Asthma - Your Personal Action Plan
Print out this action plan (PDF page 1, PDF page 2) and use to monitor you asthma. Bring it with you to your doctor appointments -- this information will be very useful in assisting him/her to assess your condition.
Date : ______
My Personal Best Peak Flow __________
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Doing Well |
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Symptoms
· No/minimal/few symptoms such as cough, wheeze, chest tightness or shortness of breath.
· No limitations in usual activities.
· My usual medicines control my asthma.
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Green Zone
Peak flow: _____to_____
(80-100% of my personal best peak flow.) |
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When I am doing well, I should follow my daily treatment plan: |
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Medicine |
Dose |
Maximum number of times/day and duration |
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Reliever: |
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Preventer : |
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Other : |
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Caution |
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Symptoms
· Presence or increase of such symptoms as cough, wheeze, chest tightness or shortness of breath (including symptoms at night.)
· Limitations in your ability to perform usual activities.
· Increased need for asthma (reliever) medicine
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Yellow Zone
Peak flow: _____to_____
(50-80% of my personal best peak flow.) |
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When I am in the caution/yellow zone, I should adjust my current medicines and/or add medicines as indicated below: |
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Medicine |
Dose |
Maximum number of times/day and duration |
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Reliever: |
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Preventer : |
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Other : |
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Caution |
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Symptoms
· Extreme cough, wheeze, chest tightness or shortness of breath (including symptoms at night.)
· Cannot perform usual activities.
· Symptoms are the same or worse after 24 hours in the CAUTION/Yellow zone.
· Asthma medicines have not reduced symptoms.
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Yellow Zone
Peak flow: _____to_____
(Less than 50% of my personal best peak flow.) |
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When I am in the medical alert/red zone, I should adjust my current medicines and/or add medicines as indicated below: |
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Medicine |
Dose |
Maximum number of times/day and duration |
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Reliever: |
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Preventer : |
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Other : |
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I should call the doctor immediately when : |
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· My reliever medicine is not helping my symptoms as well as it should.
- My shortness of breath is getting worse even when I am using my medicines properly.
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I need to go to the hospital now or call 911 now if : |
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· My reliever drug is not working.
· I suddenly feel faint or frightened.
· I have difficulty talking due to shortness of breath.
· My lips or fingernails are blue.
· A child with asthma is having a hard time breathing and is hunched over and/or struggling to breathe. |
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WHEN IN DOUBT, GO TO THE HOSPITAL. |
Emergency Telephone Numbers:
Emergency Help Line: 911 or other ____________
Nearest Emergency Room: ____________
Ambulance: ____________
My Doctor: ____________
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