"Peak Flow Trend Chart"

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Peak Flow Trend Chart
Student's Name ____________________________________________ Personal Best Peak Flow ______________________________
Green Zone
= Student’s rate: ________________ (80%-100%)
of personal best; signals all clear. No asthma symptoms are present
and the daily routine treatment can be followed.
Yellow Zone
= Student’s rate: _______________(50%-80%)
of personal best; signals caution. Symptoms may be present and a
temporary increase in medication may be indicated. Parents should be advised of measurement in this zone.
Red Zone
= Student’s rate: _______________(Below 50%)
of personal best; signals a medical alert. An immediate bronchodilator should
be taken. Notify the child’s physician if peak expiratory flow measures do not improve immediately and stay out of the red zone
Birth Date __________________________ Parents ___________________________________________________________________
Home Telephone __________________________ Emergency Contact/Phone ______________________________________________
Mother’s Work Phone __________________________________ Mother’s Cell Phone ________________________________________
Father’s Work Phone __________________________________ Father’s Cell Phone ________________________________________
Physician’ Name ______________________________________ Physician’s Phone _________________________________________
MEDICATION
Name of Medication
Dosage
Route
Frequency
1
2
3
Date _____________________________ Predicted Norm ______________________ Child's Norm ___________________________
Date
Time
650
640
630
620
610
600 --------- 600
590
580
570
560
550
540
530
520
510
500 --------- 500
490
480
470
460
450
440
430
420
410
400 --------- 400
390
380
370
360
350
340
330
320
210
300 --------- 300
290
280
270
260
250
240
230
220
210
200 --------- 200
190
180
170
160
150
140
130
120
110
100 --------- 100
90
80
70
60
50
Notes
Note Symptoms Present:
C = Cough
S = Shortness of Breath
T = Chest Tightness
E = Energy Decreased
W = Wheeze
Peak Flow Trend Chart
Student's Name ____________________________________________ Personal Best Peak Flow ______________________________
Green Zone
= Student’s rate: ________________ (80%-100%)
of personal best; signals all clear. No asthma symptoms are present
and the daily routine treatment can be followed.
Yellow Zone
= Student’s rate: _______________(50%-80%)
of personal best; signals caution. Symptoms may be present and a
temporary increase in medication may be indicated. Parents should be advised of measurement in this zone.
Red Zone
= Student’s rate: _______________(Below 50%)
of personal best; signals a medical alert. An immediate bronchodilator should
be taken. Notify the child’s physician if peak expiratory flow measures do not improve immediately and stay out of the red zone
Birth Date __________________________ Parents ___________________________________________________________________
Home Telephone __________________________ Emergency Contact/Phone ______________________________________________
Mother’s Work Phone __________________________________ Mother’s Cell Phone ________________________________________
Father’s Work Phone __________________________________ Father’s Cell Phone ________________________________________
Physician’ Name ______________________________________ Physician’s Phone _________________________________________
MEDICATION
Name of Medication
Dosage
Route
Frequency
1
2
3
Date _____________________________ Predicted Norm ______________________ Child's Norm ___________________________
Date
Time
650
640
630
620
610
600 --------- 600
590
580
570
560
550
540
530
520
510
500 --------- 500
490
480
470
460
450
440
430
420
410
400 --------- 400
390
380
370
360
350
340
330
320
210
300 --------- 300
290
280
270
260
250
240
230
220
210
200 --------- 200
190
180
170
160
150
140
130
120
110
100 --------- 100
90
80
70
60
50
Notes
Note Symptoms Present:
C = Cough
S = Shortness of Breath
T = Chest Tightness
E = Energy Decreased
W = Wheeze