My written asthma action plan helps me judge how well i am and know what i need to do if im not. Asthma is a longterm or chronic disease of the airways in the lungs. National heart, lung, and blood institute asthma action plan external icon. Breathing is easy no cough or wheeze can work and play can sleep all night. It identifies personal best peak flow, levels of symptom severity, and appropriate patient action. Take a photograph of it and keep it on your phone you. Work with your health care provider to create a plan that works for you. Learn about asthma triggers, treatment options, and more. This form must be completed by a medical provider to authorize administration of asthma medications. All people with asthma should have an asthma action plan.
Read our tips on getting the best from a childs asthma action plan. Be sure to include the three zones created by the national institutes of healthexternal icon in your plan. The aap is available in many formats and languages, as well as different sized fonts and graphics. In the 4 stage plan there is an extra step giving patients the option of increasing the dose of ics inhaled corticosteriod. I consent to communication between the prescribing health care providerclinic, the school nurse. Your goal is to prevent and control your asthma attacks. Asthma action plan library national asthma council australia. An asthma action plan also called a management plan is a written plan that you develop with your provider to help control your asthma. The student above has been instructed by me in the proper way to use hisher medications. Assess asthma control at every visit by selfadministered standardized test or verbal history. Everyone with asthma needs his or her own asthma action plan. This brochure provides an asthma action plan that will help you learn the steps to selfmanage your asthma so you can live a life as symptomfree as possible. Apr, 2020 everyone with asthma needs his or her own asthma action plan. The purpose of this asthma action plan is to help families become proactive and anticipatory with respect to asthma exacerbations and their control.
This form, when completed by health care providers, gives parents and school personnel a written asthma management plan for children. Clinical guideline for the diagnosis, evaluation, and management of adults and children with asthma 2011 pdf asthma action plan. This plan will be shared with school staff who care for my child. The asthma action plan should be used as an education and communication tool between the provider and the patient and his or her family. Using a written asthma action plan makes it easier for you to measure whether your asthma is under control and it lets you know exactly what. My asthma action plan childrens healthcare of atlanta. Management of epileptic seizure in the school setting reg 7577 attachment i. I understand that the medication must have a pharmacy label with the name of the student and the health care provider.
Work with your health care provider to create a plan for your child. If i am not back in the green zone within one hour, then i should. I authorize this medication to be administered by school personnel or. Start quickrelief medicine albuterol at home or school to stop your asthma from getting worse. The 2012 revised dc asthma action plan fillintheblank pdf form is now available in english and spanish based on the national heart, lung, and blood institute s 2007 guidelines for the diagnosis and management of asthma. Our library includes some of the many different written asthma action plans available. Many people with asthma are allergic to dust mites. The guidelines recommend that all children and adults with asthma have a written asthma action plan, developed jointly with their healthcare provider. My asthma action plan times per day every day take only noas needed see below starting in yellow zone or before excercise times per day every day times per day every day 2 puffs 46 puffs 1 nebulizer treatment gargle or rinse mouth after use special instructions when i am doing well be careful ask for help asthma triggers check all that. Asthma action plan provider instructions at initial presentation, determine the level of asthma severity level of severity is determined by both impairment and risk and is assigned to the most severe category in which any feature occurs.
To request a supply of hard copy asthma action plans, please fill out our online form or complete the order form pdf or word and submit it via email of fax. Patientcentered asthma care minnesota department of health. Maine asthma prevention and control program action management plans in pdf and information to order ncr forms. Have the following written down and kept close at hand in case of an emergency. See the reverse side for things you can do to avoid your asthma triggers. Asthma action plan name date of birth gradeteacher. Allergens animal dander some people are allergic to the flakes of skin or dried saliva from animals with fur or feathers. The smart plan is used only with the single icslaba maintenance and reliever therapy. Perform spirometry at baseline and at least every 1 to 2 years for patients 5 years of age. Swelling or inflammation in the linings of the airways. Asthma treatment plan student parent instructions the pacnj asthma treatment plan is designed to help everyone understand the steps necessary for the individual student to achieve the goal of controlled asthma. Health forms and regulations prince william county public.
Take these medicines and get help from a doctor now. All of our nonenglish asthma action plans contain information standardaccredited advice and their translation has been approved by multilingual professionals. English asthma action plan directions to the provider. Asthma triggers try to stay away from or control these things. Asthma coalition of new jersey asthma action plans in english, spanish. Massachusetts asthma action plan personal best peak flow. Asthma action plans aaps are written, individualized selfmanagement and educational tools that provide daily and emergency guidance to asthma patients, parents, and caregivers at home, school, and the workplace and community settings. It contains student medication administration authorization. Adapted from finger lakes asthma action plan and nhlbi revised 10. Asthma action plan and informational materials asthma clinical guideline tool. Asthma action plan you can use the colors of a traffic light to help learn about your asthma medicines.
English pdf spanish pdf asthma triggers at home and in the workplace. I request that the school assist my child with the above asthma medications and the asthma action plan as ordered by the health care provider in accordance with state laws and regulations. Need help speaking with your healthcare provider about your. Before taking this form to your health care provider, complete the top left section with. Asthma francais french bilingual pdf health information translations peak flow meter francais french bilingual pdf. Asthma action plan name school dob health care provider providers phone parentresponsible person parents phone additional emergency contact contact phone asthma severity see reverse side asthma triggers identified things that make your asthma worse. For more information contact the asthma society of canada at. Electronic, fillable pdf versions of asthma action plans. This guide suggests things you can do to avoid your asthma triggers. Use poison baits, powders, gels, or paste for example, boric acid.
Asthma action plan provider instructions at initial presentation, determine the level of asthma severity l level of severity is determined by both impairment and risk and is assigned to the most severe category in which any feature occurs. Our english asthma action plan has recently been updated, so the advice on the non english plans isnt exactly the same, however, they are still useful for patients and clinically safe. Health forms and regulations prince william county. Exercise smoke, strong odors or spray mold colds respiratory infections chalk dustdust carpet pollen change in temperature animals dust mites tobacco smoke cockroaches. Asthma action plans also tell school and other caregivers about your childs asthma. Minnesota department of health asthma action plans in pdf child or adult.
To access the various versions of the asthma action plans, please utilize the links below. Asthma action plan for older children childrens healthcare of atlanta. I give written authorization for the medications listed in the action plan to be administered in school by the nurse or other school members as appropriate. Virginia asthma action plan pdf administration of asthma medication pdf virginia asthma action plan pdf fillable form management of asthma in school setting reg 7575. Connecticut department of health asthma action plans in pdf and word formats. Maintaining good daytoday asthma control is the key to keeping symptoms at bay and preventing asthma attacks. Name date next asthma checkup due doctors contact details emergency contact details name phone relationship asthma action plan take this asthma action plan with you when you visit your doctor. Perform skin or blood allergy tests for all patients with persistent asthma. The asthma action plan chosen should be appropriate for the persons age, treatment regimen, asthma severity, culture, language, literacy level, and ability to selfmanage. Having a personalized asthma action plan will allow you to easily identify which zone you are in and what you must do to stay in the green zone. Create a personalized asthma action plan with your healthcare provider. Asthma action plan new york state department of health.
This could include teachers, school nurses, and after school care staff. Put a check next to the triggers that you know make your asthma worse and ask your doctor to help you find out if you have other triggers as well. I consent to communication between the prescribing health care providerclinic, the school nurse, the school medical advisor. Here is a sample asthma action plan you can use for students in school. Our english asthma action plan has recently been updated, so the advice on the nonenglish plans isnt exactly the same, however, they are still useful for patients and clinically safe. All of our non english asthma action plans contain information standardaccredited advice and their translation has been approved by multilingual professionals. Nonenglish action plans for healthcare professionals asthma uk. Then decide with your doctor what steps you will take. Take a photograph of it and keep it on your phone you can check what to do if your asthma gets worse. It is my professional opinion that heshe should be allowed to carry.