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Updated DC Asthma Action Plan Form Now Available

Download DC Asthma Action Plan Fill-in-the-Blank PDF Forms:

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UPDATED: Asthma Action Plan (English): Fill-in-the-blank PDF form (1 MB/4 pages)

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UPDATED: Plan de Acción Contra el Asma (Spanish): Fill-in-the-blank PDF form (1 MB/4 pages)

The 2012 revised DC Asthma Action Plan fill-in-the-blank PDF form is now available in English and Spanish based on the National Heart, Lung, and Blood Institute's 2007 Guidelines for the Diagnosis and Management of Asthma. The guidelines recommend that all children and adults with asthma have a written asthma action plan, developed jointly with their healthcare provider.

Initially developed in 2007 by community and government partners through the National Capital Asthma Coalition and piloted at Children's National Medical Center, this triplicate form includes copies to share with schools, childcare providers, nursing homes, and other caregivers. It also fulfills the requirements for the administration of, and/or student self-administration of, asthma and anaphylaxis medication under DC's Student Access to Treatment Act of 2007 (PDF: 42 KB/6 pages) (D.C. Law 17-107; D.C. Official Code § 38-651.01 et seq.).

For more information, contact Lisa A. Gilmore, (202) 415-1962.

 

Order DC Asthma Action Plan Form

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Order the bulk printing of triplicate carbon-copy forms customized with your organization's logo. Contact Jim Inglesby, Toucan Business Forms, 1-800-447-2950, x108, to request a quote.

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.

 

Home Search Disclaimers Privacy Policy
For more information, contact: Lisa A. Gilmore
Telephone:  (202) 415-1962 • E-Mail:  lgilmore@natcapasthma.org
The information provided on this website is not intended to diagnose health problems or to take the place of medical advice.
For asthma or any medical condition, individuals should seek medical advice from their health care professional.
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Last modified: 11/24/2014