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
