Asthma Action Plan
Patient Name
Date of Birth
Date
Provider Name
Daily Asthma Management (Green Zone)
List daily long-term control medicines and how much to take:
Other instructions:
Caution (Yellow Zone)
Symptoms (e.g., cough, wheeze, shortness of breath):
Medicine
How Much
When
Other instructions:
Danger (Red Zone)
Symptoms (e.g., trouble speaking, blue lips):
Medicine and actions to take right away:
Emergency Contact
Doctor / Clinic Name
Phone
Other Emergency Contact