Asthma Action Plan
Asthma Action Plan
I. Personal Information
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Name: [Your Name]
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Date of Birth: [Date of Birth]
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Address: [Your Company Address]
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Email: [Your Email]
II. Emergency Contacts
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Primary Emergency Contact:
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Name: Jane Smith
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Relationship: Spouse
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Phone Number: (555) 987-6543
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Secondary Emergency Contact:
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Name: Michael Johnson
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Relationship: Neighbor
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Phone Number: (555) 789-0123
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III. Asthma Diagnosis Information
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Date of Diagnosis: March 15, 2022
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Severity Level: Moderate
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Triggers: Pollen, Dust, Exercise
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Medications Prescribed:
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Albuterol (ProAir) - 2 puffs every 4-6 hours, as needed
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Fluticasone (Flovent) - 2 puffs twice daily
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IV. Asthma Symptoms
Common Symptoms:
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Shortness of Breath
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Wheezing
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Coughing
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Chest Tightness
V. Peak Flow Zones
Green Zone: 80–100% of personal best
Action: Continue regular medication as prescribed.
Yellow Zone: 50–79% of personal best
Action: Use a rescue inhaler and monitor symptoms closely.
Red Zone: Below 50% of personal best
Action: Use a rescue inhaler and seek medical help immediately.
VI. Medication Plan
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Controller Medication(s):
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Fluticasone (Flovent)
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Dosage: 2 puffs
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Frequency: Twice daily
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Reliever Medication:
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Albuterol (ProAir)
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Dosage: 2 puffs
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Instructions for Use: Inhale as needed for asthma symptoms.
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VII. Asthma Triggers and Avoidance Techniques
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Common Triggers:
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Allergens (e.g., pollen, dust mites)
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Smoke
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Exercise
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Cold air
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Avoidance Techniques:
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Use air purifiers indoors.
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Avoid outdoor activities during high pollen count days.
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Warm up before exercising.
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VIII. Follow-Up Plan
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Follow-Up Appointment: June 15, 2024
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Provider Contact: Dr. Emily Jones
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Contact Information:
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Phone Number: (555) 222-3333
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Email: emily.jones@email.com
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IX. Additional Notes
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Always carry a rescue inhaler.
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Keep track of symptoms and peak flow measurements.