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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient’s name, weight, date of birth, and peak flow in the designated fields at the top of the form.
Fill in the primary care provider's name and phone number to ensure proper communication regarding the patient's asthma management.
Identify asthma severity by listing symptom triggers and completing the sections for each zone: Green, Yellow, and Red. Each zone outlines specific symptoms and required medications.
In the Green Zone section, document daily controller medicines along with their doses. Ensure to include any necessary information about spacer usage.
For the Yellow Zone, list reliever medicines and their doses while noting peak flow ranges. Include instructions for when to contact a provider if symptoms persist.
Finally, complete the Red Zone section with emergency reliever medicines and peak flow ranges. Emphasize immediate action if symptoms worsen.
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If you do not have a written Asthma Action Plan, take the form below to your doctor and have them fill it out for you. Asthma Action Plans also tell school and other caregivers about your childs asthma. This could include teachers, school nurses, and after school care staff.
Can a pharmacist do an asthma action plan?
The Asthma Action Plan is provided to patients by either a GP or pharmacist. The treatment information should be completed, in consultation with the consumer, by their GP.
What is included in an asthma action plan?
Your asthma action plan will include your medicines and instructions for what to do when you are feeling well, what to do when you have asthma symptoms and what to do when your asthma symptoms are getting worse. It should include the names of your medicines, how much to take and when to take it.
How do I create an asthma action plan?
Your asthma action plan should include: Factors that make your asthma worse, asthma triggers Medicines you take to treat your asthma with specific names of each medicine. Symptoms or peak flow measurements (if used) that indicate worsening asthma.
Who can write an asthma plan?
An integral part of asthma management is the development of a written asthma action plan by the person with asthma and/or their carer together with their doctor.
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The document is a formal letter addressed to a former independent contractor, demanding that they cease and desist from ...
Are asthma action plans required in Illinois schools?
Illinois Public Act 099-0843 requires schools to request an Asthma Action Plan (AAP) from parents of students with asthma. The asthma action plan must be written by a doctor, kept on file in the office of the School Nurse, and be updated annually.
What is the 4x4x4 asthma action plan?
The 4x4x4 method is a simple but effective approach to managing asthma symptoms during an attack. It involves giving 4 puffs of Ventolin, the casualty talking 4 breaths after each puff and waiting 4 minutes. The goal of this technique is to regulate breathing and alleviate the symptoms of an asthma episode.
Who fills out an asthma action plan?
How to use an Asthma Action Plan: The Asthma Action Plan is filled out by a health care provider and the patient (or caregiver of a child/teen) with asthma.
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