Asthma Action Plan Worksheet

Your health care team will help you fill out your Action Plan. Provide the information requested below to see how well you are managing your asthma.

Peak flow

A peak-flow meter can help you track changes in your breathing tubes even before you have symptoms. Comparing daily measurements with your personal best number can help you track any changes. My provider said to check my peak flow at these times: ______________________________

Vaccines

People with asthma who get the flu or pneumonia are at higher risk for other illnesses and for worsening asthma. You should have a flu shot once a year. The pneumonia vaccine (pneumococcal polysaccharide vaccination) is usually a one-time dose for adults with a normal immune system who have a chronic illness and people age 65 or older. A second dose is recommended for people ages 65 and older who got their first dose when they were younger than age 65, if five or more years have passed since that dose.  Please check with your health plan to see if you’re eligible for the pneumonia vaccine.

I had my flu shot on ______________________ and my pneumonia vaccine on ________________________________                  

Asthma medications

I always keep at least a 30-day supply of asthma medications on hand.

Yes

No

Smoking

Smoking is the largest contributor to lung disease and other serious diseases. I talked with my provider about ways to stop smoking on this date: _______________________

Secondhand smoke can also contribute to worsening of asthma and other respiratory diseases. Are you regularly exposed to tobacco smoke in the home or workplace?

Yes

No

Other tests

Your health care provider may recommend a lung function test called spirometry. This test should be done as recommended by your provider but at least once a year. Date of my last test: ________________________________

If you also have allergies, identifying and avoiding your triggers can help relieve your symptoms. Your provider will recommend allergy testing if and when you need it. 

Although these are suggested guidelines for care, please check with your benefits plan for coverage.