Free 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.

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