"Asthma Action Plan" - Illinois

Asthma Action Plan is a legal document that was released by the Illinois Department of Public Health - a government authority operating within Illinois.

Form Details:

  • Released on November 1, 2004;
  • The latest edition currently provided by the Illinois Department of Public Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Illinois Department of Public Health.

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Download "Asthma Action Plan" - Illinois

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Illinois Department of Public Health
Asthma Action Plan
Patient Name__________________________________ Weight ______ Date of Birth ______________ Peak Flow ______________
Primary Care Provider Name _____________________________________ Phone __________________
Asthma Severity
Primary Care Clinic Name ________________________________________________________________
Symptom Triggers _______________________________________________________________________
Green Zone
The
GREEN ZONE
means take the following medicine(s) every day.
“Go! All Clear!”
Controller Medicine(s)
Dose
___________________________________________________________________________________________
• Breathing is easy
• Can play, work
___________________________________________________________________________________________
and sleep without
asthma symptoms
___________________________________________________________________________________________
Spacer Used
______________________________________________________________________________
Take the following medicine if needed 10-20 minutes before sports, exercise or any
other strenuous activity.
Peak Flow Range
___________________________________________________________________________________________
(80% - 100% of personal best)
Yellow Zone
The
YELLOW ZONE
means keep taking your GREEN ZONE controller medicine(s)
“Caution...”
every day and add the following medicine(s) to help keep the asthma symptoms from
getting worse.
• Breathing is easy
Reliever Medicine(s)
Dose
• Cough or wheeze
___________________________________________________________________________________________
• Chest is tight
___________________________________________________________________________________________
If beginning cold symptoms, call your doctor before starting oral steroids.
Peak Flow Range
___________________________________________________________________________________________
(50% - 80% of personal best)
Use Quick Reliever (two - four puffs) every 20 minutes for up to one hour or use nebulizer once. If your symptoms are not
better or you do not return to the GREEN ZONE after one hour, follow RED ZONE instructions. If you are in the YELLOW
ZONE for more than 12-24 hours, call your provider. If your breathing symptoms get worse, call your provider.
Red Zone
The
RED ZONE
means start taking your RED ZONE medicine(s) and call your doctor
"STOP! Medical Alert!"
NOW! Take these medicines until you talk with your doctor. If your symptoms do not get
better and you can't reach your doctor, go to a hospital emergency department or call
• Medicine is not helping
911 immediately.
• Nose opens wide to
Reliever Medicine(s)
Dose
breathe
• Breathing is hard and fast
___________________________________________________________________________________________
• Trouble Walking
___________________________________________________________________________________________
• Trouble Talking
___________________________________________________________________________________________
• Ribs show
Peak Flow Range
(Below 50% of personal best)
For more information on asthma, please visit the National Heart, Lung and Blood Institute at www.nhlbi.nih.gov, the U.S. Centers for Disease Control
and Prevention at www.cdc.gov or the U.S. Environmental Protection Agency at www.epa.gov.
If you would like more information on Illinois’ asthma program, please contact the Illinois Department of Public Health at 217-782-3300.
Printed by Authority of the State of Illinois
P.O.355503
1M
11/04
Illinois Department of Public Health
Asthma Action Plan
Patient Name__________________________________ Weight ______ Date of Birth ______________ Peak Flow ______________
Primary Care Provider Name _____________________________________ Phone __________________
Asthma Severity
Primary Care Clinic Name ________________________________________________________________
Symptom Triggers _______________________________________________________________________
Green Zone
The
GREEN ZONE
means take the following medicine(s) every day.
“Go! All Clear!”
Controller Medicine(s)
Dose
___________________________________________________________________________________________
• Breathing is easy
• Can play, work
___________________________________________________________________________________________
and sleep without
asthma symptoms
___________________________________________________________________________________________
Spacer Used
______________________________________________________________________________
Take the following medicine if needed 10-20 minutes before sports, exercise or any
other strenuous activity.
Peak Flow Range
___________________________________________________________________________________________
(80% - 100% of personal best)
Yellow Zone
The
YELLOW ZONE
means keep taking your GREEN ZONE controller medicine(s)
“Caution...”
every day and add the following medicine(s) to help keep the asthma symptoms from
getting worse.
• Breathing is easy
Reliever Medicine(s)
Dose
• Cough or wheeze
___________________________________________________________________________________________
• Chest is tight
___________________________________________________________________________________________
If beginning cold symptoms, call your doctor before starting oral steroids.
Peak Flow Range
___________________________________________________________________________________________
(50% - 80% of personal best)
Use Quick Reliever (two - four puffs) every 20 minutes for up to one hour or use nebulizer once. If your symptoms are not
better or you do not return to the GREEN ZONE after one hour, follow RED ZONE instructions. If you are in the YELLOW
ZONE for more than 12-24 hours, call your provider. If your breathing symptoms get worse, call your provider.
Red Zone
The
RED ZONE
means start taking your RED ZONE medicine(s) and call your doctor
"STOP! Medical Alert!"
NOW! Take these medicines until you talk with your doctor. If your symptoms do not get
better and you can't reach your doctor, go to a hospital emergency department or call
• Medicine is not helping
911 immediately.
• Nose opens wide to
Reliever Medicine(s)
Dose
breathe
• Breathing is hard and fast
___________________________________________________________________________________________
• Trouble Walking
___________________________________________________________________________________________
• Trouble Talking
___________________________________________________________________________________________
• Ribs show
Peak Flow Range
(Below 50% of personal best)
For more information on asthma, please visit the National Heart, Lung and Blood Institute at www.nhlbi.nih.gov, the U.S. Centers for Disease Control
and Prevention at www.cdc.gov or the U.S. Environmental Protection Agency at www.epa.gov.
If you would like more information on Illinois’ asthma program, please contact the Illinois Department of Public Health at 217-782-3300.
Printed by Authority of the State of Illinois
P.O.355503
1M
11/04