Asthma Action Plan

1. Child's Name

2. Date of Birth This question requires a valid date format of MM/DD/YYYY.

calendar

4. Other

Step 1 - Assessment

5. Usual asthma symptoms include:

6. Tightness in Chest:

Space Cell	Medication	How Much?	How Often?
	: Medication	: How Much?	: How Often?

7. Coughing/Wheezing:

Space Cell	Medication	How Much?	How Often?
	: Medication	: How Much?	: How Often?

8. Harsh Wheezing:

Space Cell	Medication	How Much?	How Often?
	: Medication	: How Much?	: How Often?

9. Difficulty Breathing:

Space Cell	Medication	How Much?	How Often?
	: Medication	: How Much?	: How Often?

10. Other?

11. Special Instructions:

If child has any of the following danger signs, call 911 immediately:

Chest sucking in
Very difficult breathing
Nostrils wide-open
Trouble talking or walking
Lips or fingernails blue or purple

Step 2 - Treatment

Give above medication as directed. Child may administer, or if necessary staff may administer medication.

Step 3 - Emergency Calls

12. Parents:

13. Phone Number 1:

14. Phone Number 2:

15. Emergency Contact #1 - Name(s):

16. Relation

17. Phone Number:

18. Emergency Contact #2 - Name(s):

19. Relation

20. Phone Number

21. Your E-mail Address (to receive a copy of your responses as a PDF to upload to ePact) *This question is required. This question requires a valid email address.