Asthma Action Plan
Name
Date of birth
Green means GO! Use preventive asthma medicine.
Parent
Parent’s number
Yellow means CAUTION. Add Yellow Zone medicine.
Doctor
Doctor’s number
Other emergency contact
Contact’s number
Red means DANGER! Use Red Zone medicine & call Dr.
Date created: __ / __ / __
Reviewed:
__ / __ / __
__ / __ / __
__ / __ / __
Student is able to self-medicate?
□ Yes □ No
Green (GO!)
 No cough,
Peak flow
wheeze,
above:
chest
_________
tightness, or
shortness of breath
 Can do usual
activities
Use preventive medicines every day:
Medicine
Continue with preventive medicine and add Yellow Zone
medicines:
Medicine
How much to take
How often/how long to take it
First, take quick-relief medicine>
Then >
Additional instructions:
 If symptoms are the same after 24 hours or get worse, call your child’s doctor.
 If your child needs Yellow Zone medicines over 2-3 times per week, call his/her doctor.
Take these medicines and call your child’s doctor:
RED (DANGER!)
 Very short Peak flow
of breath
below:
_________
 Trouble
talking or
walking
 Working hard
to breathe
 Breathing faster than
usual
 Noisy breathing even at
rest
 Very fussy
 Grey or blue skin color
How often to take it
For asthma with exercise, take:
Yellow (CAUTION)
 Cough,
Peak flow:
wheeze,
_______ to
chest
______
tightness, or _
shortness of breath
 Feels tired or
restless
 Waking at night
due to asthma
 Can’t do all of usual
activities
How much to take
Medicine
How much to take
How often/how long to take it
First, take quick-relief medicine>
Then >
Additional instructions:
Call your child’s doctor NOW!
Go to the emergency room or call 911 if:
 Your child is still in the Red Zone after 15 minutes and you cannot reach your doctor
 Your child has trouble walking or talking or lips or fingernails are blue
Please bring this plan to all doctor visits.