Asthma Action Plan

Name: ___________  Date: _________

Doctor: _____________________ Phone: (219) 483-0688

Text Box: GREEN – GO                    ุ      Breathing is good ุ      No cough or wheeze ุ      Can play   Peak Flow number  ________TO________ Text Box: Use preventative Medicine Medicine                Dose               When         20 minutes before sports take : Text Box: YELLOW – Caution ุ      Cough ุ      Wheeze ุ      Tight chest   Peak Flow number   _______TO_________   Text Box: Take quick-relief Medicine to keep an attack from getting bad Medicine                Dose            When   Text Box: RED – STOP – DANGER ุ      Meds are not helping ุ      Breathing is hard/Fast ุ      Nose opens wide ุ      Can’t walk ุ      Ribs show ุ      Cant talk well Peak Flow Numbers  _______TO__________ Text Box: GET HELP FROM A DOCTOR NOW!!!!!! Take these meds until you talk with Dr. Medicine                Dose            When    

 

 




 

Northeast Indiana Pediatric Specialists, PC

Dr. Michael Dick & Dr. Todd Dillon
11123 Parkview Plaza Drive Suite 102
Fort Wayne, IN 46845
(260) 483-0688
 http://www.med-web.com/nips/

nips@med-web.com