Dr.Kamini Silvarajan MD/AAAM

Editorial Board: Dr.Kamini Silvarajan MD/AAAM

Asthma Action Plan Form

Action Plan For Asthma

A Guideline for Managing Your Asthma

An action plan for asthma can assist you to identify early warning signs or symptoms, and how to act accordingly to prevent an asthma attack. 

This action plan is for: _____________________________

Date of plan : ____ / ____ / _____

Doctor’s Name: ____________________ Phone No: _______

Hospital or ER Address / Phone No: 
___________________________________________

My Personal Asthma Triggers ( √ ) 
__ Pollen 
__ Mold 
__ Dust 
__ Cats 
__ Dogs 
__ Fumes 
__ Cold air 
__ Smoke 
__ Others: ____________________________ 

INSTRUCTIONS: This plan is divided into 3 zones, green, yellow, and red, similar to the colors on a traffic light. If you are in the GREEN zone, then you’re doing well. You probably don’t need to do anything other than take your daily medicines as prescribed.

If you are in the YELLOW zone, it means you are getting a warning. Yellow means that your asthma may be getting worse and you are probably having a flare up. Action is needed to prevent an asthma attack.

If you are in the RED zone, you are in danger, and you MUST take emergency action, as described on the plan, right away!

The steps you need to follow are listed in each zone. If you have any questions about your Asthma Action Plan, be sure to discuss it with your doctor before you get into the yellow or red zones.

GREEN ZONE-You Are Doing Well!

Symptoms: 
You feel good 
You have no cough, wheezing, or other breathing problems 

And / Or… Peak Flow Readings Are:

At least 80% or more of my best peak flow, which would be _________

My best peak flow is __________________

Take these medicines every day (name/dose/how often): 
_____________________________________________ 
_____________________________________________ 
_____________________________________________ 

YELLOW ZONE-Your Asthma Is Getting Worse

Symptoms: 
You are having mild cough, wheezing, chest tightness or shortness of breath 
You sometimes wake up at night due to asthma 
You can do some of your usual activities, but not all 

Or Peak Flow Readings Are:

only 50 to 80% of my best peak flow: ___________________________

Actions to Take: 
Keep taking your daily medicine 
Next, add the following quick-relief medicine: __________________________ 
If your symptoms do not improve, call your doctor 

RED ZONE-Medical Alert!

Symptoms: 
  1. You are very short of breath & actively wheezing
  2. You cannot do your usual activities
  3. Quick-relief medicine is not relieving your symptoms
  4. You’ve been in the YELLOW zone for 24 hours with no improvement
Or Peak Flow Readings Are:

less than 50% of your best peak flow: __________________

Actions to Take: 
Keep taking your daily medicine 
Next, add the following quick-relief medicine: __________________________ 
Call your family doctor NOW 
If you are still in RED zone after 15 minutes AND not able to contact your doctor, then immediately GO TO THE NEAREST HOSPITAL OR CALL AN AMBULANCE! 

Extreme Danger Signs: If you see any of these, you must get emergency help immediately: 
  1. Lips or fingernails turning blue or purplish (cyanosis) 
  2. Trouble walking or talking 
  3. Chest sucking in 
  4. Nostrils flaring open 

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