Asthma: Your Action Plan

Medicine List

Controller medicine action plan

Fill in the blank spaces and boxes that apply for all sections.

• Name of your controller medicine:
  • ____________________________________________
• How much of this medicine do you take?
  • ____________________________________________
• How often do you take this medicine?
  • ____________________________________________

• Other instructions?
  • ____________________________________________

Quick-relief medicine action plan

• Name of your quick-relief medicine:
  • ____________________________________________
• How much of this medicine do you take?
  • ____________________________________________
• How often do you take this medicine?
  • ____________________________________________

Asthma Zones

GREEN ZONE: This is where you want to be!

Green zone symptoms

• You have no shortness of breath or chest tightness. You are not coughing or wheezing.
• You can do all of your usual activities.
• You sleep well at night.

Green zone peak flow (if you use a peak flow meter)

• ______ or more (80% or more of your personal best)

Green zone actions (Check the boxes and fill in the blank spaces that apply.)

[ ] You take your controller medicine(s) every day.

[ ] You are staying away from your asthma triggers.

[ ] You take quick-relief medicine (called _____________________) ______ minutes before exercise.

YELLOW ZONE: Your asthma is getting worse.

Yellow zone symptoms

• You are short of breath or have chest tightness. You are coughing or wheezing.
• You have symptoms that keep you up at night.
• You can do some, but not all, of your usual activities.

Yellow zone peak flow (if you use a peak flow meter)

• ______ to ______ (50% to 79% of your personal best)

Yellow zone actions (Check the boxes and fill in the blank spaces that apply.)

[ ] Take _____ puff(s) of quick-relief medicine called ______________________. Repeat _____ times.

[ ] If your symptoms don't get better or your peak flow has not returned to the green zone in 1 hour, then:

• [ ] Take _____ puff(s) of medicine called ______________________. Take it ____ times a day.
• [ ] Begin or increase treatment with corticosteroid pills. Take ______ mg of medicine called ____________________________ every __________.
• [ ] Call your doctor at this number: ____________________.

RED ZONE: Danger!

Red zone symptoms

• You are very short of breath.
• You can't do your usual activities.
• Quick-relief medicine doesn't help. Or your symptoms don't get better after 24 hours in the yellow zone.

Red zone peak flow (if you use a peak flow meter)

• Less than _______ (less than 50% of your personal best)

Red zone actions (Check the boxes and fill in the blank spaces that apply.)

[ ] Take _____ puff(s) of quick-relief medicine called ____________________________. Repeat ______ times.

[ ] Begin or increase treatment with corticosteroid pills. Take ________ mg now.

[ ] Call your doctor at this number: _________________. If you can't contact your doctor, go to the emergency department. Call 911 or ___________________.

[ ] Other numbers you might call are: ___________________________________.