Tools for Managing Asthma —
Asthma Action Plan

If you or your child has asthma, you should have an Asthma Action Plan.

Asthma Action PlanPeople with asthma should routinely check in with their health care provider and have an asthma action plan to help identify triggers in the environment to change or avoid, recognize symptoms, and know when and how to use medications and seek medical attention.

The Vermont Asthma Action Plan is a form that serves as your written asthma management plan in a simple and user-friendly format.

Complete Your Asthma Action Plan

How to get the Asthma Action Plan Form
  1. From your doctor or your child's doctor
    The doctor can help explain the Asthma Action Plan and answer any questions you may have. If the plan is for your child, be sure that you and your doctor both sign it, and send the second page to your child's school nurse. Keep the plan where you can find it quickly in an emergency.

    - OR -

  2. Print the Asthma Action Plan Form PDF document

    - OR -

  3. Order a Hard Copy:
    1. Contact your local District Office for a copy
    2. Order by phone: 1-866-331-5622 (toll free) or 1-802-863-7514
    3. Mail your request:
      Vermont Department of Health
      Asthma Program
      108 Cherry St., P.O. Box 70
      Burlington, VT 05402-0070

Important Tips about Your Asthma Action Plan and staying healthy:

Return to Top

About the Vermont Asthma Action Plan

The Action Plan form was created by the Vermont Asthma Advisory Panel to help improve asthma care statewide through the use of written asthma management plans. When a child is involved, the plan provides a tool to improve asthma management and related communication between health care providers and the child's school nurse.

Developed initially for use with children, the plan can also be used with adults.

The actual Vermont Asthma Action Plan document is a triplicate form with the green, yellow and red zones printed on each page. The physician and parent signatures at the bottom of the page authorize the school nurse or child care provider to exchange information and oversee or administer asthma medications.

The back of the third page addresses trigger control and medication tips as well as resource contacts. It is designed to aid patient education. A peak flow chart is also provided for those individuals for whom peak flow readings are recommended. The form can be used to manage asthma using either symptoms or peak flow readings.

Contact us

Contact us with any questions or for more information about asthma.

Vermont Asthma Program
Vermont Department of Health
108 Cherry Street, PO Box 70
Burlington, VT 05402
Tel: 1-800-439-8550
Email: Vermont Asthma Program

Return to Top