My asthma action plan

Patient Name:
MY Asthma Action Plan
Use traffic light colors to help control asthma.
Asthma Severity † Intermittent: Symptoms < 2/days/wk; < 2 nights/mo † Mild Persistent: Symptoms > 2 days/wk; 3-4 nights/mo
Classification* † Moderate Persistent: Symptoms daily; > 5 nights/mo † Severe Persistent: Symptoms continual; frequent nights
* These are partial criteria for Severity Classification. See national guidelines (EPR-3) for complete criteria:
Every-Day Medicines for Prevention and Long-Term Control at home
I Feel Good
• Breathing is good, and • No cough, tight chest, or wheeze, and At 15 to 20 minutes before sports or hard play take:
_____ sprays albuterol, using spacer
Continue the Green Zone Every-Day Medicine, and
I Don’t Feel Good
Start QUICK-RELIEF Medicine (albuterol) at home or school to stop
1. Start albuterol (inhaler with spacer, or by machine) now:
2. If not improved in 30 minutes, repeat __ sprays albuterol.
3. If improved, then _____ sprays every _____ hours, as needed until • Cough, • Congested/ • Trouble breathing, _________________________________________________. or Tight Chest, or or wheezing
If not improved after taking ____ sprays of albuterol ___ times, or
if still in Yellow Zone after_____________ days, then start _______________ and phone Your Doctor: _______________
Take Quick-Relief Medicine and get help from a doctor,
I Feel Awful
1. Take albuterol right away: _____ sprays or by machine and
2. Start corticosteroid: __________________________ mg. and
• Severe chest tightness/congestion, or 3. Repeat albuterol ___ sprays or by nebulizer, if necessary, AND
• Trouble talking or walking (EMERGENCY) or
• Blue lips/nails or drowsy (EMERGENCY)
GO TO EMERGENCY ROOM / Call 911 NOW. Do Not Wait!
If you go to the Emergency Room, make appointment with your
doctor the next day.
Authorization and Disclaimer from Parent/Guardian: I request that the school assist my child with the above asthma medications
and the Asthma Action Plan in accordance with state laws and regulations. † Yes † No My child may carry and self-administer asthma medications and I agree to release the school district and school personnel from all claims of liability if my child suffers any adverse reactions from self-administration of asthma medications. † Yes † No
Print Parent/Guardian Name:__________________________________ Signature:_________________________________ Date: _______________
Health Care Provider: My signature provides authorization for the above written orders. I understand that all procedures will be implemented
in accordance with state laws and regulations. Student may carry and self-administer asthma medications: † Yes † No (This authorization is for a maximum of one year from signature date.) Print Provider Name/Credentials: _______________________________ Signature:_____________________________ Date:__________ Provider Phone #: ________________________ Provider Address: ________________________________________________________ 6/09 dapted from materials of Community Clinic Association, Long Beach Alliance for Children with Asthma and The Children’s Clinic, Long Beach CA PATIENT COPY



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Liste plantes soniam (english).xlsx

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