Scribd
Upload
349 views

Aap-Form 1 5

Uploaded by

api-369839863
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
349 views

Aap-Form 1 5

Uploaded by

api-369839863
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

ASTHMA ACTION PLAN FOR HOME AND SCHOOL

Name:
Use the traffic light colors to show when to give your asthma
DOB (mm/dd/yyyy): medicines :
1.GREEN means GO. Use your everyday preventive medicines
Diagnosis: 2.YELLOW means BE CAREFUL!! Use quick-relief medicine.
3.RED means DANGER!! Use extra medicines and call your doctor NOW!!!
GREEN means GO!!!
USE PREVENTION MEDICINES EVERY DAY
* Breathing is good Not Applicable (no prevention medicines)
* No cough or wheeze Medicine How Much to Take Times to Take
Take at:
* Can work and play Home? School?

~ 20 minutes before exercise use this medicine as needed

If needed more than once a day, contact your doctor

YELLOW means BE CAREFUL!!!! START TAKING QUICK RELIEF MEDICINE


1.TAKE QUICK-RELIEF MEDICINE TO KEEP AN ASTHMA ATTACK FROM GETTING BAD

~ ~
Tight Chest Wheeze
2.KEEP TAKING GREEN ZONE MEDICINES
Medicine How Much to Take Times to Take Take at:
Home? School?

*If you DO NOT feel much better 20-60 minutes after taking YELLOW ZONE medications, FOLLOW RED ZONE
Cough day or night *IF SYMPTOMS CONTINUE FOR 12 TO 24 HOURS, CALL YOUR DOCTOR
RED means DANGER!!! GET HELP FROM A DOCTOR NOW !!!
* Medicine is not helping GO TO DOCTOR'S OFFICE OR EMERGENCY ROOM!
* Breathing is hard and fast TAKE THESE MEDICINES UNTIL YOU SEE THE DOCTOR.
* Nose opens wide to breathe
* Can't talk well Medicine How Much to Take

Up To times, 20 min. apart

1rtr CALL 911 (EMS) IF: Lips or fingernails are blue, or


You are struggling to breathe, or
,r,r
You do not feel or look better in 20-30 minutes
Air Quality Alert Days:
The national recommendation is to avoid outdoor exercise when levels of air pollution are high.
Physician recommendations for medication self-administration: (Health Care Provider must select one below)
The student above has been instructed by me in the proper way to use their medications. It is my professional opinion that
the student SHOULD be allowed to carry and self-administer the above medications while on school property or at school-
related events. (Optional for middle & high school students. NOT recommended for elementary students.)
The student above, in my professional opinion, should NOT be allowed to carry and self-administer any of the student's
asthma medication(s) while on school property or at school-related events. (Recommended for all elementary students.)

Printed Name of Health Care Provider Signature of Health Care Provider Phone Number Date
I, ______________________________________, agree with the recommendations of my child's physician as noted above and give
permission for my child to receive the above medication(s) as directed. I also give permission for my child's physician and the school
nurse to share written or verbal information for the duration of this school year.

Signature of parent/guardian Date

Home Telephone Work Telephone Cell Phone


Ver. 2/2024. ADAPTED FROM: The Global Initiative for Asthma (NIH Publication No.96-3659C. Dec. 1995) and Christus Santa Rosa Children's Hospital and CentroMed, San Antonio

You might also like