Pediatric Asthma Action Plan
Child's Name
Date of Birth
Date
Parent/Guardian
Doctor/Clinic
Phone
Daily Asthma Management
Controller Medicine(s) (Name, Dose, When to take)
Other instructions
Asthma Zones
Green Zone: Doing Well (No Symptoms)
Continue daily medicine
Yellow Zone: Caution (Symptoms Present)
Symptoms and Actions
Red Zone: Danger (Severe Symptoms or Not Improved in Yellow Zone)
Emergency Actions
Peak Flow Monitoring (if used)
Green Zone
Yellow Zone
Red Zone
Emergency Contact Information
Emergency contact name
Relationship
Phone
Doctor's Signature
Date