Your goal is to prevent and control your asthma attacks. A list of the persons triggers and how to avoid them, instructions for taking asthma medicine, information on what to do during an asthma episode, instructions on when to call a doctor, and. Danger take these medicines and call your doctor now. Every person with asthma should have an asthma action plan aap in writing. Asthma action plan check all items that trigger your asthma and things that could make your asthma worse. Washington state asthma plan 2016 about the asthma plan this updated version of the washington state asthma plan reflects the current landscape of asthma care and management in washington. Assess asthma control to determine if therapy should be adjusted see page 6. Date hospitalemergency department phone number green zone doing well no cough, wheeze, chest. Brief report asthma action plans in the adult population. Symptoms are same or worse after 24 hours in the yellow zone or very short of breath or. Follow the yellow and red zone plans for rescue medicines according to asthma symptoms. Asthma action plans are written documents developed by you and your health care provider, listing customized steps to prevent and handle an asthma episode.
Assess asthma severity to initiate treatment see page 5. Date hospitalemergency department phone number green zone doing well no cough, wheeze, chest tightness, or shortness of breath during the day or night can do usual activities and, if a peak flow meter is used, peak flow. This brochure is a asthma selfmanagement action plan for adults to be completed by doctors together with their patients with asthma. The asthma action plan chosen should be appropriate for the persons age, treatment regimen, asthma severity, culture, language, literacy level, and ability to selfmanage. The most secure digital platform to get legally binding, electronically signed documents in just a few seconds. Here is a sample asthma action plan you can use for students in school.
Select the one that is best for you, print a copy and fill in the information requested. Look out for common triggers that can make asthma worse. I give permission for the medicines listed in the action plan to be administered in school by the nurse or other school staff as appropriate. Asthma treatment plan student parent instructions the pacnj asthma treatment plan is designed to help everyone understand the steps necessary for the individual student to achieve the goal of controlled asthma. This brochure provides an asthma action plan that will help you learn the steps to selfmanage your asthma so you can live a life as symptomfree as possible. Asthma treatment plan student parent instructions the pacnj asthma treatment plan is designed to help everyone understand the steps necessary for the individual student to achieve the goal of. During an asthma attack, the air passages airways of the lungs become inflamed, swollen and narrowed. Ask your doctor questions talk about concerns, including medication. To be completed by parentguardian and student student asthma action card continued student name. An asthma action plan should have information that details the course of action when such asthma aggravations occur. Using the vermont asthma action plan vermont department.
Every person living with asthma should have an asthma action plan. Asthma action plan asthma australia nations peak consumer. Download national asthma council asthma action plan pdf. If a spray is used to kill roaches, stay out of the room until the odor. Put a check next to the triggers that you know make your asthma worse and ask your doctor to help you find out if you have other triggers as well. Rediscovering an invaluable tool in todays health care. A written asthma action plan, developed jointly by the health care provider and the patient, will help the patient manage his or her asthma.
Severity classification intermittent mild persistent moderate persistent severe persistent. Asthma action plan pdf fill out and sign printable pdf. Washington state asthma plan 2016 about the asthma plan this updated version of the washington state asthma plan reflects the current landscape of asthma care and management in. You may experience other symptoms, and your doctor may recommend other actions, than those listed. Nac aap colour nac aap black and white an aap provides clear information and instructions for managing your asthma.
For more information contact the asthma society of canada at. I should continue using my normal medications as directed by my doctor, and remeasure my peak flow every weeks months. Asthma action plans are written documents developed by you and your health care provider, listing customized steps to prevent and. Coordinated federal action plan to reduce racial and ethnic asthma disparities pdf 24 pp, 1. This is the asthma action plan for dc public schools provided by the department of health. This plan will be shared with school staff who care for my child. It is important make an asthma action plan that works well for you. An asthma action plan is an important tool to share with caregivers of children with asthma, including daycare providers, schools and aftercare programs. If student stays in red zone, begin emergency plan. A written asthma action plan encourages selfmanagement of asthma. My written asthma action plan helps me judge how well i am and know what i need to do if im not.
Connecticut department of health asthma action plans in pdf and word. Aug 24, 2019 use the action plan to recognize the signs of rapidly worsening asthma. Intermittent mild persistent moderate persistent severe persistent heshe has had many or severe asthma attacksexacerbations. I consent to communication between the prescribing health care provider or clinic, the school nurse, the school medical advisor and school.
A list of the persons triggers and how to avoid them, instructions for taking asthma medicine, information on what to do during an asthma episode, instructions on when to call a doctor, and emergency telephone numbers. Asthma action plan name date of birth date health care provider providers phone parentresponsible person parents phone school additional emergency contact contact phone last. An asthma action plan, also known as an asthma management plan, is a detailed plan that an asthma patient should make with the help of his doctor to help him control his condition. Create an asthma action plan american lung association. You may need a pdf reader to view some of the files on this page.
Use the schoolaged asthma action plan, asthma action plan for home and school that includes language for schoolaged children to selfcarry their asthma inhaler in school. Use poison baits, powders, gels, or paste for example, boric acid. Asthma action plan national heart, lung, and blood institute. Get copies of common action plan templates on our sensitive choice website. Coordinated federal action plan to reduce racial and.
Asthma action plans respiratory health association. I need to see my asthma nurse every six months parents get the most from your childs action plan make it easy for you and your family to find it when you need it. An asthma action plan should include some basic details, to begin with. Be sure to include the three zones created by the national institutes of healthexternal icon in your plan. Work with your health care provider to create a plan for your child. Asthma action plan name school dob health care provider providers phone parentresponsible person parents phone additional emergency contact contact phone asthma severity see reverse side. Everyone with asthma needs his or her own asthma action plan. Asthma symptom control means how often in the last four weeks you had asthma symptoms, used your reliever. This asthma action plan is adapted from the asthma action plan created by the national institutes of health.
Understand what type of asthma you have or your child has. Name date next asthma checkup due doctors contact details emergency contact details name phone relationship asthma action plan take this asthma action plan with. Discuss the plan at each visit and change it as needed. Name asthma action plan, for children 6 years or older. If you do not have a written asthma action plan, take the form below to your doctor and have them fill it out for you. Read our tips on getting the best from a childs asthma action plan. Allergens animal dander some people are allergic to the flakes of skin or dried saliva from animals with fur or feathers. Before taking this form to your health care provider, complete the top left section with. This leads to coughing, wheezing and shortness of breath. Asthma action plan health library unitedhealthcare. If student improves to yellow zone, send student to doctor or contact doctor. If you or someone you are responsible for has asthma, ask about developing an asthma action plan with your doctor. Adult asthma action plans this brochure is a asthma selfmanagement action plan for adults to be completed by doctors together with their patients with asthma.
Apr, 2020 everyone with asthma needs his or her own asthma action plan. Next asthma checkup due doctors contact details emergency contact details name phone relationship asthma action plan take this asthma action plan with you when you visit your doctor. Intermittent mild persistent moderate persistent severe persistent heshe has had many or severe asthma attacksexacerbations school staff. Asthma action plans national asthma council australia. Call your asthma provider breathing is hard and fast ribs show when breathing cant sleep or play because of. This guide suggests things you can do to avoid your asthma triggers. Green zone doing well breathing is good no coughing, wheezing, chest tightness, or. Written asthma action plans are one of the most effective asthma management tools available. Asthma action plan, for children 6 years or older, continued doctor doctors phone number. The asthma action plan chosen should be appropriate for the persons age, treatment. An asthma action plan is especially important if you have moderate to severe asthma or youve had a serious asthma attack in the past. Many people with asthma are allergic to the dried droppings and remains of cockroaches. The colors of a traffic light will help you use your asthma medicines.
We eagerly look forward to the continued evolution of the plan over time. Take a photograph of it and keep it on your phone you can check what to do if your asthma gets worse. Everyone with asthma should have an asthma action plan in writing. The vermont asthma action plan is a medical form that helps you or your caregivers. The washington asthma initiative and the washington state department of health support the plan. Asthma control means the extent to which the effects of asthma can be seen, or have been reduced or removed by treatment. Asthma action plan library national asthma council australia.
My asthma action plan name date doctor doctors phone number symptoms my breathing is normal. A list of the persons triggers and how to avoid them, instructions for taking asthma medicine, information on what. Adapted from finger lakes asthma action plan and nhlbi revised 10. I need to see my asthma nurse every six months parents get the most from your childs action plan make it easy for you and your family to find it when you need it take a photo and keep it on your mobile and your childs mobile if they have one stick a copy on your fridge door share your.
Fill out, securely sign, print or email your asthma action plan pdf asthma and allergy foundation of america aafa instantly with signnow. Asthma action plan for adults american lung association. Minnesota department of healths interactive asthma action plan is a computerbased program that uses information entered by the healthcare provider to create a personalized plan for each patient. This could include teachers, school nurses, and after school care staff. Asthma action plans also tell school and other caregivers about your childs asthma. Then decide with your doctor what steps you will take. Our library includes some of the many different written asthma action plans available. There are many different asthma action plan formats.
The action plan may have a place for you to list your asthma triggers and notes on how to avoid them. Green use these medicines every day to prevent asthma attacks. Symptoms are same or worse after 24 hours in the yellow zone or very short of breath or quickrelief asthma medicines have not helped or cannot do usual activities work, play peak flow meter if used. If you or someone you are responsible for has asthma, ask about developing an asthma action plan with your. Massachusetts asthma action plan personal best peak flow.
Coordinated federal action plan to reduce racial and ethnic asthma disparities pdf 24 pp, 1 mb. Asthma action plan name date of birth gradeteacher. Asthma action plan take this asthma action plan with you when you visit your doctor if symptoms get worse severe asthma flareup attack needing reliever again within 3 hours, increasing difficulty breathing, waking often at night with asthma symptoms peak flow if used between and other instructions contact your doctor today. Work with your health care provider to create a plan that works for you. If you use a peak flow meter, the action plan will also tell you when low peak flow readings signal that an asthma attack has become an emergency. This plan provides information and instructions on how you can manage your asthma. Asthma action plan this information is for general purposes and is not intended to replace the advice of a qualified health professional. Asthma action plans asthma initiative of michigan aim. Take your asthma action plan to your school, childcare provider and your home. Thick mucus may be produced and breathing becomes difficult. This is the asthma action plan for dc public schools.
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