Your name:

_________________________

Emergency contact:

_________________________

Healthcare provider:

_________________________

Today's Date:

_________________________

Phone:

_________________________

Signature:

_________________________

Next appt (date/time):

_________________________

Phone:

_________________________

Phone:

_________________________

• No wheezing, coughing, or chest tightness

• Asthma is not bothering your sleep, work, or school

• You rarely or never use your quick-relief medicine

Peak flow is:

_____________________

80%-100% of personal best

• Keep taking your long-term  controller medicines

• Take your quick-relief
  medicines as needed

Avoid your asthma triggers (list):

__________________________

__________________________

__________________________

__________________________

__________________________

Long-term controllers:

__________________________

Name:

__________________________

Dose:

__________________________

How often:

__________________________

Special instructions:

__________________________

Quick-relief:

__________________________

__________________________

Before exercise:

__________________________

• Some wheezing, coughing, or chest tightness

• When at rest, your breathing is a little faster than normal

• Asthma symptoms wake you up at night

Peak flow is:

___________________________

50%-80% of personal best, or
has lessened by at least 15%

You begin to have symptoms of a respiratory infection, if infections trigger your symptoms

• Keep taking your long-term controller medicines

• Use your quick-relief medicine

• If you do not feel better within an hour after using your quick-relief medicine, make sure you know what to do! You might use more medicine or use another medicine.

• Call your healthcare provider if you are unsure

Continue to take long-term controllers:

_________________________

Name:

_________________________

Dose:

_________________________

How often:

_________________________

Special instructions

_________________________

Name:

_________________________

Dose:

_________________________

How often:

_________________________

Special instructions:

_________________________

Quick-relief:

_________________________

_________________________

If your symptoms don't go away after 1 hour, take:

_________________________

• Continuous wheezing, coughing, or trouble breathing

• Trouble walking or talking

• Asthma symptoms make it hard for you to sleep

Peak flow is:

__________________________

Less than 50% of personal best

• Use your quick-relief medicines

• Call your healthcare provider

Call 911 if:

• It is getting harder to breathe

• You can't walk or talk

• Your lips or fingers look gray or blue

Quick-relief:

__________________________

__________________________

Quick-relief:

__________________________

__________________________

Quick-relief:

__________________________

__________________________