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Your Asthma Zone Action Plan (Adult)

Name:                                Personal Best Peak Flow:               Date:                                    

Provider’s Telephone:                                   After-hours Telephone:                                   

 

Green Zone

Peak flow is greater than

                         (80%)

See provider every ______ months.

Symptoms:

  • None

  • Asthma doesn’t affect work, activities, or sleep

Asthma Medications

Controller medication(s), take daily:

                                    

Quick relief, take           minutes before exercise:

                                  

                                  

Other medication(s):

                                    

                                    

Yellow Zone

Peak flow is between

                        (50%) and

                        (80%)

Call provider if in yellow zone for              hours.

Symptoms:

  • Coughing

  • Wheezing

  • Shortness of breath

  • Chest tightness

  •                             

  •                             

Asthma Medications

Quick-relief, take for symptoms:

                                     

Controller medication(s), increase for            days:

                                  

                                  

Other medication(s), add for            days:

                                     

                                   

Red Zone

Peak flow is less than

                         (50%)

Call provider’s office!

Symptoms:

  • Constant coughing or wheezing

  • Trouble breathing at rest

  • Any severe symptoms

Asthma Medications

Quick-relief, take for symptoms:

                                   

Controller medication(s), increase for           days:

                                    

                                    

Other medication(s), add for            days:

                                   

                                   

Call 911 if you have:

  • Severe trouble breathing

  • Trouble walking across room or finishing sentence

  • Blue lips or fingers

Author: StayWell Custom Communications
Last Annual Review Date: 8/14/2003
Copyright © The StayWell Company, LLC. except where otherwise noted.
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