High Quality
Open the downloaded document, and select print from the file menu (PDF reader required).
Sheet1Page 1
P e a k F l o w R a t e
Date
Signs
Green Zone90%_____ 80%_____ HighYellow Zone70%_____ Low60%_____ Yellow Zone50%_____ Red Zone
M e d i c i n e s
*Maintanence Inhaler *Quick Relief Inhaler *Oral Steroid*Other Meds*Other Meds* Other Meds
S i g n s
WheezeCoughActivitySleep
*Write in the name of the medication, dose and a “Check Mark” for each time you used that medicine during the day.Day123456789101112131415Before TXAfter TX
AsthmaDiary
PEAKFLOW
Triggers,Comments,Activities
O
– Before Tx
X
– After Tx
100%
_____
u
Wheeze:
(0)None(1)End of Exhale(2)Throughout exhale(3)Inhale and exhale
u
Cough / past 5 min:
(0)None(1)<1 per minute(2)1-4 per minute(3)>4 per minute
u
Activity:
(0)Fully active(1)Run short distance(2)Can walk only(3)Missed workor schoolor stayed indoors
u
Sleep:
(0)Fine(1)Slightwheeze/cough (2)Awake2-3x because of wheeze/cough(3)Awake most of night
Column DColumn FColumn HColumn JColumn LColumn NColumn PColumn RColumn TColumn VColumn XColumn ZColumn ABColumn ADColumn AF024681012Before TXAfter TX
Sheet1Page 2
Add a Comment
David Kirkleft a comment