Asthma Action Plan
Patient Information
Name
Date of Birth
Contact Number
Physician
Emergency Contact
Name
Phone
Asthma Severity & Triggers
Severity
Known Triggers
Medications
Medication
Dosage
When to Take
Personal Best Peak Flow
Management Zones
Green Zone (Doing Well)
Symptoms
Actions
Yellow Zone (Caution)
Symptoms
Actions
Red Zone (Emergency)
Symptoms
Actions
Additional Instructions
Physician Signature
Signature
Date