ASTHMA Care Plan

Student Name:*
Grade:*
Age:*
Homeroom Teacher:
Location:
Parent/ Guardian 1 Name:*
Parent/ Guardian 1 Contact Number:*
Parent/ Guardian 2 Name:
Parent/ Guardian 2 Contact Number:
Emergency Contact Name:
Relationship:
Emergency Contact Number:
Go Maintain Therapy
- Breathing is easy
- No coughing
- No wheezing
- No shortness of breath
- Work, play, and sleep easy
- Using quick-relief medication less than twice a week
- PEAK FLOW 80% – 100% of personal best
Go Peak flow from
To
Go Peak Flow To
• Asthma triggers list:
• Take CONTROLLER medication (includes anti-inflamatory). Name, Amount and When to use:
- Take QUICK-RELIEF medication:
before exercise take puffs
- Before exercise, take ______ puffs 5-60 minutes before exercise.
Medication Name
CAUTION Step up therapy
- Using quick-relief medication more than twice a week
- Coughing
- Wheezing
- Shortness of breath
- Difficulty with physical activity
- Waking at night
- Tightness in chest
- PEAK FLOW 50% – 80% of personal best
Caution Peak Flow from
To
Caution Peak Flow to
Step 1: Add QUICK-RELIEF medication:
• Take

Puffs
• Frequency
Step 2: Monitor yours symptoms:
- If symptoms GO AWAY quickly, return to green zone.
- If symptoms CONTINUE or return within a few hours:
Add (medication name) (dose) mg
- Add (medication name) (dose) mg
Medication Name
Dose (mg)
Frequency:
Step 3: Continue monitoring your symptoms:
- If symptoms CONTINUE after Step 2 treatment:
CONTINUE after Step 2 treatment:
- Add (medication name) mg
- Call Parent
Medication Name
STOP Get Help NOW
- Medication is not helping
- Breathing is very difficult
- Cannot walk or play
- Cannot talk easily
- PEAK FLOW Less than 50% of personal best
Stop Peak Flow
- Call for help immediately
- Sit up, don’t lie down. Try to be calm.
- Call Parents
- Call Ambulance if available
If an oral steroid, take:
Medication Name
Dose
as you leave the Hospital
- Continue to use your QUICK-RELIEF medication:
Puffs:
Frequency
Asthma symptoms can get worse quickly. When in doubt, seek medical help.
authorize inhaler
- I authorize my child to carry his own inhaler.
Signature*
Email*
Date*
MM slash DD slash YYYY
Medication Expires:*
MM slash DD slash YYYY