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SAMPLE ASTHMA ACTION PLAN Name Asthma Action Plan, for Children 0–5 Years DOB Record Health Care Provider’s Name Health Care Provider’s Phone Number Completed by .Date Long-Term Control Medicines (Use every day to stay healthy) Other Instructions How Much To Take How Often (such as spacers/masks, nebulizers times per day EVERY DAY times per day EVERY DAY times per day EVERY DAY Quick-Relief Medicines How Much To Take How Often YELLOW ZONE GREEN ZONE Give ONLY as needed Child is WELL and has no asthma symptoms, Prevent asthma symptoms every day even during active play • Give the above long-term control medicines every day • Avoid things that make the child’s asthma worse  Avoid tobacco smoke, ask people to smoke outside    Child is NOT WELL and has asthma symptoms that may incude: • Coughing • Wheezing • Runny nose or other cold symptoms • Breathing harder or faster • Awakening due to coughing or difficulty breating • Playing less than usual • • Other symptoms that could indicate that your child is having trouble breathing may include: difficulty feeding (grunting sounds, poor sucking), changes in sleep patterns, cranky and tired, decreased appetite Child FEELS AWFUL warning signs may incude: • Child’s wheeze, cough or difficult breathing continues or worsens, even after giving yellow zone medicines RED ZONE Other Instructions NOTE: If this medicine is needed often ( per week), call physician • Child’s breathing is so hard that he/she is having trouble walking/talking/eating/playing • Child is drowsy or less alert than normal DANGER Get help immediately Call 9-1-1 if: CAUTION: Take action by continuing to give regular asthma medicines every day AND:  Give (include dose and frequency) If the Child is not in the Green Zone and still has symptoms after 1 hour:  Give  Give  Call (include dose and frequency) (include dose and frequency) MEDICAL ALERT Get help  Take the child to the hospital or call 9-1-1 immediately  Give more  Give m

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