Tools for Managing Asthma —
Asthma Action Plan
If you or your child has asthma, you should have an Asthma Action Plan.
The Vermont Asthma Action Plan is a form that serves as your written asthma management plan in a simple and user-friendly format.
- what medicines to take to stay healthy
- list of asthma triggers to avoid
- how to recognize and treat asthma episodes & when to seek help
Complete Your Asthma Action Plan
How to get the Asthma Action Plan Form
- 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 -
- Print the Asthma Action Plan Form
- OR -
- Order a Hard Copy:
- Contact your local District Office for a copy
- Order by phone: 1-866-331-5622 (toll free) or 1-802-863-7514
- 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:
- Make sure you keep your asthma action plan up to date. At least yearly, and more often if your medical provider changes your asthma management plan or medications.
- Make sure you understand how to use this plan. Discuss each part of the plan with your medical provider and ask questions if you do not understand what actions to take.
- Keep your asthma action plan with you at all times.
- For adults: keep a copy at home, in your purse or wallet, in your car, and other places (such as at work)
- For children: make sure the school nurse, child care provider, sports coach, baysitters, and other have copies.
- Take steps to avoid asthma triggers
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 first page is intended to be kept by the physician
- the second page should be sent to the school nurse or early childcare provider, if a child is involved
- the third page given to the patient or parent
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