Transcription of CNMC Asthma Action Plan UPO
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CNMC Asthma Action Plan UPO
Asthma Action PlanName SchoolDOBH ealth Care ProviderProvider s PhoneParent/Responsible PersonParent s PhoneAdditional Emergency ContactContact PhoneAsthma Severity(see reverse side) Asthma Triggers Identified (Things that make your Asthma worse): Intermittent orPersistent: Mild Moderate SevereAsthma Control Well-controlled Needs better control Colds Smoke (tobacco, incense) Pollen Dust Animals_____ Strong odors Mold/moisture Pests (rodents, cockroaches) Stress/emotions Gastroesophageal reflux Exercise Season: Fall, Winter, Spring, Summer Other:_____ /___ /___Green Zone: Go! Take these CONTROL (PREVENTION) Medicines EVERY DayYou have ALLof these: Breathing is easy No cough or wheeze Can work and play Can sleep all night No control medicines required. Always rinse mouth after using your daily inhaled medicine. _____ , _____ puff(s) inhaler with spacer_____ times a dayInhaled corticosteroid or inhaled corticosteroid/long-acting agonist _____ , _____ nebulizer treatment(s)_____ times a dayInhaled corticosteroid _____ , take_____ by mouth once daily at bedtimeLeukotriene antagonistFor Asthma with exercise, ADD: _____ , _____ puff(s) inhaler with spacer 15 minutes before exerciseFast-acting inhaled agonistFor nasal/environmental allergy, ADD: _____Yellow Zone: Caution!
Asthma Action Plan Name School DOB Health Care Provider Provider’s Phone Parent/Responsible Person Parent’s Phone
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