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My Asthma Symptom Diary

Keep track of symptoms with the chart below. (Make some copies first.) Show your records to your healthcare provider at your visits. As your asthma control improves you should have fewer episodes of symptoms to record.

 

Date

Symptoms

Possible triggers

Action taken

Results

 

3/3

Example:

Wheezing, peak flow 75%

 

Cold air

 

2 puffs albuterol, went inside

 

Symptoms gone in 20 min.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Author: StayWell Custom Communications
Last Annual Review Date: 12/15/2009
Copyright © The StayWell Company, LLC. except where otherwise noted.
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