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Asthma Action Plan Worksheet

To help you manage your asthma, your health care team will help you fill out your Asthma 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 health care 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. People over age 19 should get this vaccine. A one-time revaccination is recommended for people ages 65 and older who got their first dose when they were younger than age 65, if 5 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 health care provider about ways to stop smoking on this date: _______________________

Other tests

Your health care provider may recommend a lung function test called spirometry. This test should be done as recommended by your health care 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 health care provider for a discussion of other Action Plan areas unique to your personal situation.