Asthma Action Plan |
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For School or Child Care |
Name: _________________________________________ |
Date of Birth: ____________________ |
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Parent/Guardian Name:____________________________ |
Phone: __________________________ |
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Parent/Guardian Name:____________________________ |
Phone: __________________________ |
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Emergency Contact (1): |
________________________ |
___________________ |
_____________ |
Name |
Relationship |
Phone |
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Emergency Contact (2): |
________________________ |
___________________ |
_____________ |
Name |
Relationship |
Phone |
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Physician Name: ________________________________ |
Phone: __________________________ |
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Other Physician: ________________________________ |
Phone: __________________________ |
Asthma Triggers - Identified items which may cause asthma attacks (circle all that apply):
dust mites strong odors tobacco smoke colds/infections mold mice/rats exercise temperature change pets pollen chalk dust excitement cockroach dust smoke (other than tobacco) pesticides food (specify):_________________________________________________________________ other (specify):_________________________________________________________________
Activities - that have caused asthma attacks in the past (circle all that apply):
art projects with dust or fumes playing outdoors on cold/windy days sitting on carpeting playing in freshly cut grass pet care gardening wood/kerosene heated rooms running hard other (specify):____________________________________________________________________
Peak Flow Monitoring
Personal best peak flow reading:_______________________________________________________
Reading to give quick-relief medication:__________________________________________________
Reading to get medical help:___________________________________________________________
Typical Signs and Symptoms - of asthma attacks (circle all that apply):
persistent cough flaring nostrils/panting dark circles under eyes wheezing breathing faster gray or blue lips/fingernails shortness of breath grunting sucking in chest/neck restlessness fatigue trouble talking/walking
Reminders:
Notify parents immediately if emergency medication is required.
Seek emergency medical care if:
there are no improvements 15-20 minutes after initial treatment with mediation and family can not be reached
after receiving treatment for asthma symptoms, the child has
• chest / neck pulled in with breathing | • gray or blue lips / fingernails |
• trouble talking / walking | • hunched over |
Asthma Action Plan |
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For School or Child Care |
Condition |
Medications and Action Steps | |||||||||||||||||||
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G |
All Clear
____________________ Good Control |
Quick Relief Medicine should not be needed except before exercise and exposure to a known trigger Before exercise and exposure to a known trigger take: |
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Y |
Asthma Symptoms
Caution |
Continue taking Green Zone Medicines and ADD:
Continue with Yellow Zone action for ______ hours |
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R E D Z O N E |
Danger!
Medial Alert!!
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Continue taking Yellow Zone Medicines and ADD:
Start oral steroids if not already
Call physician right away! |
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Danger Signs |
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Physician’s Signature:_________________________________________ | Date:____________________ |
Parent / Guardian Signature:____________________________________ | Date:____________________ |