Your name:

_________________________

Emergency contact:

_________________________

Healthcare provider:

_________________________

Today's date:

_________________________

Phone:

_________________________

Signature:

_________________________

Next appt (date/time):

_________________________

Phone:

_________________________

Phone:

_________________________

• No wheezing, coughing, or chest tightness

• Asthma is not bothering your sleep, work, or school

• You rarely or never use your quick-relief medicine

Peak flow is:

_____________________

80%-100% of personal best

• Keep taking long-term controller medicines, preventive medicines, or both

• Call your healthcare provider if your medicines are not controlling your asthma

Stay away from your asthma triggers (list):

__________________________

__________________________

__________________________

__________________________

__________________________

Special instructions (before exercise, field trips, or outdoor activities):

___________________________

___________________________

Name:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

Name:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

• Mild wheezing, coughing during day and night, or chest tightness

• When at rest, your breathing is a little faster than normal

• Asthma symptoms wake you up at night

Peak flow is:

___________________________

50%-80% of personal best, or
has lessened by at least 15%

You begin to have symptoms of a respiratory infection or a cold, if infections trigger your symptoms

• Keep taking  long-term controller medicines, preventive medicines, or both

• Use your quick-relief medicine

• Follow your healthcare provider's instructions if you don't feel better within an hour after using your quick-relief medicine

• Call your healthcare provider right away if you are unsure of what to do

Long-term controllers:

Name:

_________________________

Dose and how taken:

_________________________

How often and when:

_________________________

Special instructions:

_________________________

Name:

_________________________

Dose and how taken:

_________________________

How often and when:

_________________________

Special instructions:

_________________________

Quick-relief medicine:

Name:

_________________________

Dose and how taken:

_________________________

How often and when:

_________________________

If your symptoms don't go away after 1 hour, take:

_________________________

Dose and how taken:

_________________________

How often and when:

_________________________

• Continuous wheezing, coughing, or trouble breathing

• Trouble walking or talking

• Asthma symptoms make it hard for you to sleep

Peak flow is:

__________________________

Less than 50% of personal best

• Use your quick-relief medicines

• Call your healthcare provider right away if these medicines don't help you breathe better

Call 911 if:

• It's hard to breathe, walk, or talk

• Your lips or fingers look pale, gray, or blue

• You feel confused, lightheaded, or dizzy

• You have tightness in your throat or chest

Quick-relief medicine:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

Quick-relief medicine:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

Quick-relief medicine:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________