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Asthma Action Plan General Information: ■ Name ■ Emergency contact numbers ■ Physician/healthcare provider numbers ■ Physician signature ❍ Intermittent ❍ Moderate Persistent ❍ Mild Persistent ❍ Severe Persistent Severity Classification ❍ Colds ❍ Smoke ❍ Weather ❍ Exercise ❍ Dust ❍ Air Pollution ❍ Animals ❍ Food ❍ Other Triggers 1. Premedication (how much and when) 2. Exercise modifi cations Exercise Green Zone: Doing Well Peak Flow Meter Personal Best = ■ Breathing is good ■ No cough or wheeze ■ Can work and play ■ Sleeps well at night Peak Flow Meter More than 80% of personal best or Medicine How Much to Take When to Take It Control Medications: Yellow Zone: Getting Worse Contact physician if using quick relief more than 2 times per week. ■ Some problems breathing ■ Cough, wheeze, or chest tight ■ Problems working or playing ■ Wake at night Peak Flow Meter Between 50% and 80% of personal best or to Medicine How Much to Take When to Take It Continue control medicines and add: IF your (and peak fl ow, if used) return to Green Zone after one hour of the quick-relief treatment, THEN ❍ Take quick-relief medication every 4 hours for 1 to 2 days. ❍ Change your long-term control medicine by ❍ Contact your physician for follow-up care. IF your (and peak fl ow, if used) DO NOT return to Green Zone after one hour of the quick-relief treatment, THEN ❍ Take quick-relief treatment again. ❍ Change your long-term control medicine by ❍ Call your physician/Healthcare provider within hour(s) of modifying your medication routine. Red Zone: Medical Alert Ambulance/Emergency Phone Number: ■ Lots of problems breathing ■ Cannot work or play ■ Getting worse instead of better ■ Medicine is not helping Peak Flow Meter Less than 50% of personal best or to Medicine How Much to Take When to Take It Continue control medicines and add: Go to the hospital or call for an ambulance if: ❍ Still in the red zone after 15 minutes. ❍ You have not been able to reach your physician/healthcare provider for help. ❍ Call an ambulance immediately if the following danger signs are present: ❍ Trouble walking/talking due to shortness of breath. ❍ Lips or fi ngernails are blue. Rev_July_2008