Your child's name:

Today's date:

Next appt (date/time):

__________________________

__________________________

__________________________

Emergency contact:

Phone:

Phone:

__________________________

__________________________

__________________________

Healthcare provider:

Signature:

Phone:

__________________________

__________________________

__________________________

• No wheezing, coughing, or chest tightness

• Asthma is not bothering your child's sleep, work, or school

• Your child rarely or never uses his or her quick-relief medicine

Peak flow is:

___________to_______________

80% to 100% of personal best

• Have your child keep taking long-term controller medicines, preventive medicines, or both

• Call your child's healthcare provider if the medicines are not controlling your child's asthma

Keep your child away from his or her asthma triggers (list):

__________________________

__________________________

__________________________

__________________________

__________________________

__________________________

Special instructions (before exercise, field trips, or outdoor activities):

___________________________

___________________________

Name:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

Name:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

• Mild wheezing, coughing during day and night, or chest tightness

• When at rest, your child's breathing is a little faster than normal

• Asthma symptoms wake your child up at night

Peak flow is:

____________to______________

50% to 80% of personal best, or has lessened by at least 15%

Your child begins to have symptoms of a respiratory infection or a cold, if infections trigger your symptoms

• Have your child keep taking long-term controller medicines, preventive medicines, or both

• Give your child his or her quick-relief medicine

• Follow the healthcare provider's instructions if your child does not feel better within an hour after using the quick-relief medicine

• Call your child's provider right away if you are not sure what to do

Long-term controllers:

Name:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

Special instructions:

__________________________

Name:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

How often:

__________________________

Special instructions:

__________________________

Quick-relief medicine:

Name:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

If your child's symptoms don't go away after 1 hour, give your child:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

• Continuous wheezing, coughing, or trouble breathing

• Nostrils open in and out (flare) or ribs show when your child breathes in

• Trouble walking or talking

• Asthma symptoms make it hard for your child to sleep

Peak flow is:

____________to______________

Less than 50% of personal best

• Have your child use quick-relief medicines

• Call your child's healthcare provider right away if medicines don't help your child breathe better

Call 911 if:

• It's hard for your child to breathe, walk, or talk

• Your child's lips or fingers look pale, gray, or blue

• Your child feels confused, lightheaded, or dizzy

• Your child has tightness in his or her throat or chest

• Your child remains in the red zone after 15 minutes

Quick-relief medicine:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________

Quick-relief medicine:

__________________________

Dose and how taken:

__________________________

How often and when:

__________________________