North Dakota Asthma Action Plan
SFN 190
Name

	Date:

	
The colors of a traffic light will help you use your asthma medicines:

Red: Danger Zone!
Get help from a doctor

Yellow: Caution Zone!
Add quick-relief medicine

Green: Go Zone!
Use preventive medicine

Personal Best: ______
	
Parent(s) Name(s)                                                 

	Phone #
			
Emergency Contact                                                

	Phone #
			
Pharmacy Name                                                     

	Phone #
			
Health Care Provider                                              

	Phone #
			
Health Care Provider’s Signature                          

GO!		Use these anti-inflammatory medicines every day:		

•	Breathing is good
•	No cough or wheeze
•	Sleep through the night
•	Can work and play
•	__________________

Peak Flow
Reading Above

____________	MEDICINE	HOW MUCH	HOW OFTEN	
•					
•					

For asthma with exercise, take:	

Caution!		Continue with green zone medicine and add:	

•	First signs of a cold
•	Exposure to a known trigger
•	Cough day or night
•	Mild wheeze
•	Tight chest
•	__________________

Peak Flow From

_____  to ______ 	MEDICINE	HOW MUCH	HOW OFTEN	

	
Did symptoms improve or peak flow return to green zone?	
	YES			NO	
				
	MEDICINE	HOW MUCH	HOW OFTEN	Call Your Health Care Provider	

		
Danger!		Take these medicines and call your health care provider now.	

•	Medicine is not helping
•	Breathing is hard and fast
•	Nose opens wide / ribs show
•	Can’t talk well
•	__________________

Peak Flow
Reading Below

___________	MEDICINE	HOW MUCH	HOW OFTEN	

	GET HELP FROM A HEALTH PROVIDER NOW!  It’s important!  If you cannot contact your provider, call 911 or go directly to the emergency room. DO NOT WAIT!
                                                                                                    For asthma information contact :                                                                                                                             
                                                                                                                                      American Lung Association of N.D.
                                                                                                                      1-800-252-6325
                                                                                                                                        For additional copies contact :	
                                                                                                                                                                                                              Children’s Special Health Services                                    
                                                              Copy for Patient                                                1-800-755-2714
N.D. State Asthma Workgroup                            N.D. Department of Health                             N.D. Department of Human Services