Fillable Form 2014

Healthy Breathing for Life

Asthma Action Plan

Provider: Please discuss and complete this Asthma Action Plan (AAP) with eligible Alliance members and fax it to the

Alliance at 877-793-8504. Provide the original AAP to the patient.

Patient name: _______________________________________ Alliance ID #:________________________

Patient phone number: ________________________________ Date of birth:________________________

Provider name: ______________________________________ Practice NPI: ________________________

Provider phone number: _______________________________ Today’s date: _______________________

Asthma Severity (check one): Intermittent Mild Persistent* Moderate Persistent* Severe Persistent*

Asthma Triggers: Colds Exercise Animals Dust Pollution Weather Allergies

*Patients with any type of persistent asthma should be prescribed a controller medication.

Green Zone Doing Well!

Controller Medicines - Take these every day.

Peak flow more

than:____________ Which medicine?

How much do I

take? When do I take it?

Breathing well

No coughing

No wheezing

Can play or work

Yellow Zone Use Caution!

Rescue Medicines - Take these when you have a flare-up. (Continue to take Controller Medicines, as shown above.)

Peak flow between:

________&________ Which medicine?

How much do I

take? When do I take it?

Breathing is worse

Coughing

Wheezing

Hard to play or work

Red Zone Emergency! Medical Alert – TAKE THESE AND CALL YOUR DOCTOR OR 911!

Peak flow less than:

________ Which medicine?

How much do I

take? When do I take it?

Get Help Fast!

Rescue medicine is

not helping

Very short of breath

Hard to talk or walk

Doctor’s Comments: Check this box if patient would benefit from clinical asthma education.

X

Patient Signature {By Signing this form, I know what to do to keep my asthma symptoms under control.} DATE