Asthma Action Plan Form
Complete this form to document asthma symptoms, triggers, medications, and zone-based action instructions for safe asthma self-management.
Patient and Care Team Information
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Primary Caregiver / Parent / Guardian Name
First Name
Middle Name
Last Name
Emergency Contact Name
*
First Name
Middle Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Care Provider Name
*
Clinic / Hospital Name
*
Asthma Status and Triggers
Asthma diagnosis status
*
Diagnosed with asthma
Possible asthma symptoms, not formally diagnosed
No asthma diagnosis
Unsure
Known triggers
Pollen
Dust
Smoke
Pets
Exercise
Cold air
Infections
Strong odors
Other specified trigger
Daytime symptom frequency
*
None
Less than 2 days per week
2 or more days per week
Daily
Multiple times per day
Nighttime symptoms
Never
1-2 times per month
1 time per week
2 or more times per week
Most nights
Activity limitation due to asthma
None
Mild
Moderate
Severe
Recent urgent care or ER visit for asthma
*
No
Yes, urgent care
Yes, emergency room
Yes, both urgent care and emergency room
Details about recent asthma episodes or trigger patterns
Medication and Treatment Plan
Controller Medication Name and Dosage
*
Rescue Inhaler Name and Dosage
*
Use Spacer or Nebulizer
*
Spacer
Nebulizer
Both
Neither
Unsure
Medication Timing and Instructions
Known Medication Allergies or Sensitivities
None known
Pollen-related medications
Steroid sensitivity
Inhaler propellant sensitivity
Milk protein sensitivity
Latex sensitivity
Other
Daily Controller Inhaler Use and Rescue Inhaler Availability
*
Controller inhaler used daily and rescue inhaler kept available
Controller inhaler used daily but rescue inhaler not kept available
Controller inhaler not used daily and rescue inhaler kept available
Neither used daily nor kept available
Unsure
Symptom Zones and Action Instructions
Green Zone: Daily status
*
Breathing is good
No cough or wheeze
Can do usual activities
Other
Green Zone: What should the patient do?
*
Yellow Zone: Warning signs
*
Coughing more than usual
Wheezing or chest tightness
Using rescue inhaler more often
Other
Yellow Zone: What should the patient do?
*
Red Zone: Emergency signs and immediate action
*
Appointments, Follow-up, and Consent
Follow-up Appointment
Preferred Follow-up Timing
Please Select
Morning
Afternoon
Evening
Anytime
I will schedule later
Preferred Reminder Contact Method
Phone call
Text message
Email
Portal message
No reminders
Submit Action Plan
Should be Empty: