Sheet1

Asthma
Diary Triggers,
PEAK Comments,
Activities
FLOW
O – Before Tx
Signs
X – After Tx Date
100%_____ uWheeze:
(0)None
(1)End of Exhale
Green Zone 90%_____
Peak Flow Rate

(2)Throughout exhale
(3)Inhale and exhale

80%_____ uCough / past 5 min:

(0)None
High (1)<1 per minute
(2)1-4 per minute
Yellow Zone 70%_____ (3)>4 per minute

uActivity:
Low 60%_____ (0)Fully active
Yellow Zone (1)Run short distance
(2)Can walk only
50%_____ (3)Missed work
or school
Red Zone or stayed indoors
uSleep:
*Maintanence Inhaler (0)Fine
(1)Slight
wheeze/cough (2)Awake
*Quick Relief Inhaler 2-3x because of
Medicines

wheeze/cough
*Oral Steroid (3)Awake most of night

*Other Meds

*Other Meds

* Other Meds
Wheeze
Signs

Cough
Activity
Sleep
*Write in the name of the medication, dose and a “Check Mark” for each time you used that medicine during the day.

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Before TX
After TX

12

10

6
Before TX
After TX

0
Column F Column J Column N Column R Column V Column Z Column AD
Column D Column H Column L Column P Column T Column X Column AB Column AF

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