Student Asthma Action Plan

Student Information

Name Date of Birth School Grade Parent/Guardian Phone Number Physician Name Physician Phone

Asthma Triggers

Daily Control Medication(s)

Medication	Dose	Time

Reliever Medication(s)

Medication	Dose	Time

Green Zone: Doing Well

Symptoms Actions

Yellow Zone: Caution

Symptoms Actions

Red Zone: Medical Alert

Symptoms Actions

Emergency Contact

Name Relationship Phone

Additional Notes

Physician Signature Date