Download/Print Copy of Montana Student Asthma Action Plan
Montana Student Asthma Action Plan
Download/Print Copy of Montana Student Asthma Action Plan
- Student
- School Nurse/Emergency Staff Phone
- Fax
- Teacher
- Parent/Guardian
- Phone
- Student’s Healthcare Provider
- Phone
- Fax
Green Zone
Student is feeling well
- No difficulty participating in usual activities
- No chest tightness, shortness of breath, wheezing, or coughing during the day or night
Take these controller medications every day:
- Medicine
- Dosage
- When to Take it
Before exercise:
- Medication
- Dosage
- minutes prior to activity
Yellow Zone
Student is not feeling well
- Chest tightness, shortness of breath, wheezing, or coughing with usual activities
- Waking at night due to asthma symptoms
Continue taking controller medication(s) and add these quick-relief medications:
- Medicine
- Dosage
- When to Take it
Call student’s healthcare provider if:
Red Zone
Alert! Contact student’s healthcare provider or call 911 if:
- Quick-relief medication is not helping
- Breathing is hard and fast
- Ribs are showing and nostrils are flaring
- Can’t walk or talk well
Take the following medications, and call the healthcare provider or contact EMS right away:
- Medicine
- Dosage
- When to Take it
Other key medical information
- Student self-carries rescue medication
- Rescue medication is stored
- The student’s asthma triggers are
- Reviewed by parent/guardian
- Date
- Reviewed by school nurse/emergency staff
- Date
- Reviewed by student’s healthcare provider
- Date