Free Asthma Action Plan Template

Asthma Action Plan


I. Personal Information

  • Name: [Your Name]

  • Date of Birth: [Date of Birth]

  • Address: [Your Company Address]

  • Email: [Your Email]

II. Emergency Contacts

  • Primary Emergency Contact:

    • Name: Jane Smith

    • Relationship: Spouse

    • Phone Number: (555) 987-6543

  • Secondary Emergency Contact:

    • Name: Michael Johnson

    • Relationship: Neighbor

    • Phone Number: (555) 789-0123

III. Asthma Diagnosis Information

  • Date of Diagnosis: March 15, 2022

  • Severity Level: Moderate

  • Triggers: Pollen, Dust, Exercise

  • Medications Prescribed:

    • Albuterol (ProAir) - 2 puffs every 4-6 hours, as needed

    • Fluticasone (Flovent) - 2 puffs twice daily

IV. Asthma Symptoms

Common Symptoms:

  • Shortness of Breath

  • Wheezing

  • Coughing

  • 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

  • Controller Medication(s):

    • Fluticasone (Flovent)

      • Dosage: 2 puffs

      • Frequency: Twice daily

  • Reliever Medication:

    • Albuterol (ProAir)

      • Dosage: 2 puffs

      • Instructions for Use: Inhale as needed for asthma symptoms.

VII. Asthma Triggers and Avoidance Techniques

  • Common Triggers:

    • Allergens (e.g., pollen, dust mites)

    • Smoke

    • Exercise

    • Cold air

  • Avoidance Techniques:

    • Use air purifiers indoors.

    • Avoid outdoor activities during high pollen count days.

    • Warm up before exercising.

VIII. Follow-Up Plan

  • Follow-Up Appointment: June 15, 2024

  • Provider Contact: Dr. Emily Jones

  • Contact Information:

    • Phone Number: (555) 222-3333

    • Email: emily.jones@email.com

IX. Additional Notes

  • Always carry a rescue inhaler.

  • Keep track of symptoms and peak flow measurements.

Plan Templates @ Template.net