New DC Asthma Action Plan Form Available Below

In 2007, DC launched its first-ever standard Asthma Action Plan form for children and adults developed collaboratively by members of NCAC's Health Services & Quality Improvement Committee, piloted at Children's National Medical Center, and endorsed by the DC Department of Health. The form includes copies to share with schools, childcare providers, nursing homes, and other caregivers. It also fulfills the requirements for student self-administration of asthma medication under DC's Student Access to Treatment Act of 2007 (PDF: 42 KB/6 pages).

The National Heart, Lung, and Blood Institute's 2007 revised Guidelines for the Diagnosis and Management of Asthma recommends that all children and adults with asthma have a written asthma action/management plan, developed jointly with their healthcare provider. More information and resources are available in our Managing Asthma and Allergies in DC Schools Guide. For all other requests, contact Lisa A. Gilmore, (202) 415-1962.

Download DC Asthma Action Plan Form

Asthma Action Plan -- PDF Computer-Based Form

INSTRUCTIONS: This PDF form may be saved on your computer, filled out electronically, and saved separately for each individual (use "Save As" command). To customize, type healthcare provider's contact information in top left corner. Click or tab to blank lines to type in information and left-click on mouse to add or remove check marks in boxes. It may take a few moments for the form to fully download.

Asthma Action Plan (English) - Computer-Based Form (PDF: 987 KB/5 pages)

Plan de Acción Contra el Asma (Spanish) - Computer-Based Form (PDF: 1,019 KB/5 pages)

Asthma Action Plan -- PDF Document

Asthma Action Plan (English) - Document (PDF: 709 KB/5 pages)

Plan de Acción Contra el Asma (Spanish) - Document (PDF: 710 KB/5 pages)

How to Use an Asthma Action Plan

Asthma Action Plans provide a detailed outline of how to manage asthma on a day-to-day basis and describes what to do in an emergency. An Asthma Action Plan should be completed by a healthcare provider in partnership with the patient. Asthma Action Plans come in a number of different formats but most commonly use a three-color (zone) system like that of a traffic signal:

Green Zone = Go

Yellow Zone = Caution

Red Zone = Danger.

Each zone has assessment measures and tailored instructions specific to that zone. When you match the symptoms (and peak flow measurements, if available) to the correct color section, you will find the steps to take. Most individuals can benefit from using both symptoms and peak flow measurements to determine their current asthma zone, but either method is acceptable.

Sponsors

The DC Asthma Action Plan was funded wholly, or in part, by the Government of the District of Columbia, Department of Health, Community Health Administration, District of Columbia Control Asthma Now (DC CAN) Program.

Acknowledgements

The National Capital Asthma Coalition coordinated the development of the Asthma Action Plan with Children's National Medical Center, DC's four Medicaid managed care organizations (AMERIGROUP, DC Chartered Health Plan, Health Right, Inc., and Health Services for Children with Special Needs, Inc.), DC Department of Health, DC Public Schools, Mary's Center for Maternal and Child Health, Georgetown KIDS Mobile Medical Clinic, Howard University Hospital, and other DC healthcare providers.