MAINE ASTHMA ACTION / MANAGEMENT PLAN Name:Date of Birth:Personal Best / Predicted Peak Flow: Symptoms: Action to Take: GREEN ZONE PEAK FLOW = ________ -- _______ You are doing great if:
Continue to take your regular controller medicines every day (see blue box below).
You aren’t coughing, wheezing or having Controller medicine is not needed
You can sleep through the night without
Use your quick relief medication every 4-6 hours if needed for symptoms of cough, wheeze,
shortness of breath or dropping peak flows (see yellow zone)
Exercise pre-treatment: Take your quick relief inhaler_____________________10-15 80-100% of personal
( fill in name of inhaler and # of puffs)
Avoid your triggers: YELLOW ZONE PEAK FLOW = _______ -- _______ Keep taking your controller medicines. START QUICK RELIEF MEDICATION: (√ appropriate box (es); specify dose) Your asthma is getting worse if:
Make sure that your inhaler is primed first use a spacer/ chamber
more than 2 extra times per week
Other: _______________________________________________________________________
You are waking at night due to cough or
wheeze more than 2 times a month
_______________________________________________________________________
Your peak flow is 50-80% of personal
∗If AT SCHOOL, give the quick relief inhaler, then CALL PARENT; may repeat medicine in
10 minutes if not back into green zone. ∗If quick relief medicine is not working or you are not getting better in 24-48 hours, call your healthcare provider.
RED ZONE : GET HELP NOW if: PEAK FLOW <________ 4 puffs of quick relief inhaler medicine now
You have a hard time walking or talking
Skin in your neck or between ribs pulls in Your quick relief medicine is not helping
Call your healthcare provider now or go to the emergency department ORCall 911
Your peak flow < 50% of personal best Controller Medications for Persistent Asthma: Controller Medication Frequency
Use your regular preventive controller
medication EVERY DAY as prescribed by your doctor. This will help your
asthma stay in control by decreasing the
Other: ____________________________________________________________________ ____________________________________________________________________
If patient is a student in school or daycare: Parent / Guardian Phone Numbers: ________________________________
____________________________________________________________________
Inhaled Asthma Medicine Yes No Epi-Pen Yes No N/A
I authorize the exchange of medical information about my child’s asthma between the physician’s office and school nurse. PARENT / GUARDIAN SIGNATURE: ____________________________________ DATE: ______________
TO BE COMPLETED BY PHYSICIAN / HEALTHCARE PROVIDER: NO changes from previous plan
This student has the knowledge to carry and use: Inhaled Medication Yes No Epi-Pen Yes No
Please contact healthcare provider and parent if student is using quick relief medicine more than 2 times a week (i.e. in excess of pre-exercise treatment) HEALTHCARE PROVIDER NAME : __________________________________ PHONE #: ___________________ FAX #:________________ HEALTH CARE PROVIDER SIGNATURE:_______________________________ DATE: ____________
TO BE COMPLETED BY SCHOOL NURSE: Maine law now permits students to carry and use inhaled medications and epi-pen after demonstrating
appropriate use to school nurse. This student demonstrates knowledge / skill to carry and use: Quick Relief Inhaler Yes No Epi-Pen Yes No SCHOOL NAME: ______________________________ SCHOOL NURSE SIGNATURE _______________________________ DATE:_______________ FAX #:____________________ PHONE #:_________________________ EMAIL : _________________________ REVISED 11/30/07
ADVERSE REACTION NEWSLETTER 1999:2 This newsletter contains information reported toinformation reported does not necessarily reflectthe official views, decisions or policies of theInternational Drug Monitoring; however, the NATIONALLY CIRCULATED mainly associated with the dihydropyridine calcium channelblockers (CCBs) INFORMATION Brunet L, Miranda J, Farré M, Berini L, Mendieta C. G
Mittagundi Asthma Form Participant’s Name: _______________________________ Date: IMPORTANT INFORMATION FOR PARENTS/GUARDIAN Asthma is a potentially serious condition. Both you and your child should have a good understanding of the severity of the Asthma suffered and know how the necessary management practices for Monitoring, Prevention and Relief of Asthma. This is best established b