For adults and families managing asthma day to day, the American Lung Association's plan lays out green, yellow and red zones, with controller and quick-relief medicines, doses and timing in each zone, including SMART/MART dosing with an ICS-formoterol inhaler. It lists triggers, severity, vaccination status, danger signs that call for 911, and emergency contacts. The second page shows how to use a metered-dose inhaler with a spacer.
The patient's health care provider fills in the plan with the patient, including severity, triggers, medicines and zones. This general version has no signature block; the home and school version carries the signatures.
Download the current version from the source each time; forms change without notice.
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Yes. ALA posts the general plan in English and Spanish, titled Mi Plan de accion de asma, and also in Hebrew, Haitian Creole, Russian and Ukrainian. The home and school version comes in English, Spanish, Haitian Creole, Russian and Ukrainian, while the home and childcare version is English only.
Yes. The green, yellow and red zones each have a SMART/MART line for an ICS-formoterol inhaler with a spacer, with a daily maximum of 12 puffs for ages 12 and over and 8 puffs for ages 4 to 11. Other controller and quick-relief medicines can be written in alongside.