Illinois Department of Public Health
Asthma Action Plan
Patient Name__________________________________ Weight ______ Date of Birth ______________ Peak Flow ______________
Primary Care Provider Name _____________________________________ Phone __________________
Primary Care Clinic Name ________________________________________________________________
Symptom Triggers _______________________________________________________________________
Asthma Severity
Green Zone
“Go! All Clear!”
Peak Flow Range
(80% - 100% of personal best)
• Breathing is easy
• Can play, work
and sleep without
asthma symptoms
Yellow Zone
“Caution...”
Peak Flow Range
(50% - 80% of personal best)
• Breathing is easy
• Cough or wheeze
• Chest is tight
Red Zone
"STOP! Medical Alert!"
Peak Flow Range
(Below 50% of personal best)
• Medicine is not helping
• Nose opens wide to
breathe
• Breathing is hard and fast
• Trouble Walking
• Trouble Talking
• Ribs show
The GREEN ZONE means take the following medicine(s) every day.
Controller Medicine(s) Dose
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Spacer Used ______________________________________________________________________________
Take the following medicine if needed 10-20 minutes before sports, exercise or any
other strenuous activity.
___________________________________________________________________________________________
The YELLOW ZONE means keep taking your GREEN ZONE controller medicine(s)
every day and add the following medicine(s) to help keep the asthma symptoms from
getting worse.
Reliever Medicine(s) Dose
___________________________________________________________________________________________
___________________________________________________________________________________________
If beginning cold symptoms, call your doctor before starting oral steroids.
___________________________________________________________________________________________
The RED ZONE means start taking your RED ZONE medicine(s) and call your doctor
NOW! Take these medicines until you talk with your doctor. If your symptoms do not get
better and you can't reach your doctor, go to a hospital emergency department or call
911 immediately.
Reliever Medicine(s) Dose
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Use Quick Reliever (two - four puffs) every 20 minutes for up to one hour or use nebulizer once. If your symptoms are not
better or you do not return to the GREEN ZONE after one hour, follow RED ZONE instructions. If you are in the YELLOW
ZONE for more than 12-24 hours, call your provider. If your breathing symptoms get worse, call your provider.
For more information on asthma, please visit the National Heart, Lung and Blood Institute at www.nhlbi.nih.gov, the U.S. Centers for Disease Control
and Prevention at www.cdc.gov or the U.S. Environmental Protection Agency at www.epa.gov.
If you would like more information on Illinois’ asthma program, please contact the Illinois Department of Public Health at 217-782-3300.
Printed by Authority of the State of Illinois
P.O.355503 1M 11/04
