Pediatric Asthma Diary Tearpad

Personal Best Peak Flow # child’s name

Wheeze

Cough

None = 0 Occasional = 1 Frequent = 2 Continuous = 3

None = 0 Occasional = 1 Frequent = 2 Continuous = 3

Activity

Normal = 0 Can run short distance = 1 Can walk only = 2 Missed school or stayed indoors = 3

Adapted with permission from National Asthma Education and Prevention Program, Expert Panel Report 2, National Institutes of Health.

Quick-Relief Medicines

Shortness of breath

Sleep

Activity

Wheeze

Fill in the blocks under “Asthma Signs” by using numbers in the key at the bottom of this diary. Fill in the names of your child’s medicines, and write in the number of times a day he takes them.

Triggers/Comments Date

Cough

Asthma Signs

How to use

Fine Slept well, slight wheeze or cough Awake 2–3 times, wheeze or cough Bad night, awake most of the time

= ______

green

50-80%

= ______ yellow

below-50%

= ______

red

Daily Peak Flow Scores AM

Sleep

80-100%

PM

Other Times

Shortness of breath =0 =1 =2 =3

Fine Slept well, slight wheeze or cough Awake 2–3 times, wheeze or cough Bad night, awake most of the time

=0 =1 =2 =3 Copyright © 2000–2015 Pritchett & Hull Associates, Inc. DO NOT DUPLICATE. Product # 311

Asthma diary: working with your child’s doctor To manage your child’s asthma, you must know his signs of a flare-up (wheezing, coughing, activity, sleep).

You must also learn what triggers (causes) these. This asthma diary can help you and your child’s doctor develop a personal treatment plan. It will also help the doctor know if the plan is working.

the time and what he was doing just before the signs began. Note if he had a cold, runny nose or earache.

3. Asthma signs: Use the key code at the bottom of the page to describe your child’s signs. For example, if he has had no coughing during the past 24 hours, put a zero in the “cough” column.

If he has had a frequent cough, write 2 in that space. When your child’s asthma is under good control, he should have none of the signs.

If your child’s doctor prescribes a peak flow meter, write his personal best peak flow number in the space at the top right side of the diary. Ask the doctor or nurse how to measure this number. List the names of his medicines in the spaces at the top of the “Medicines” column.

4. Medicines: Put a number in the box under each medicine to show how many times he took that medicine during the last 24 hours.

Each day, fill in the following:

5. Daily peak flow scores: Put his daily peak flow scores for morning (AM) and afternoon/evening (PM) in the boxes for that day. (The doctor will tell you what times to take the reading.)

1. Date: Fill in the date.

2. Triggers/Comments: Write down what you think triggered the flare-up or what your child’s signs were. Note where he was, what he was doing at

Personal Best Peak Flow #

Rachel

_________ 200

child’s name

Quick-relief Medicines

Asthma Signs

How to use

Sleep

Shortness of Breath

Atrovent

Proventil

10-9

Runny nose, dry cough

0

1

0

0

0

2x

0

180

180

–

10-10

Awake, complains of stuffy nose

0

1

0

2

0

2x

0

170

160

–

10-11

Wet cough, won’t eat, circles under eyes

0

2

2

3

1

2x

3x

150

160

–

10-12

Proventil by nebulizer—4x

0

1

3

2

1

2x

4x

170

170

–

Date

Triggers/Comments

Wheeze

Activity

50% =_________ 100

Cough

Fill in the blocks under “Asthma Signs” by using numbers in the key at the bottom of this diary. Fill in the names of your child’s medicines, and write in the number of times a day he takes them.

160 80% =_________ Daily Peak Flow Scores AM

PM

Other Times

®

Pritchett & Hull Associates, Inc. 3440 Oakcliff Rd, NE, Suite 110 Atlanta, GA 30340-3079 1-800-241-4925 This information is from the Pritchett & Hull booklet: Kids Breathe Free!—A parent’s guide for treating children with asthma Copyright © 2000–2015 Pritchett & Hull Associates, Inc. DO NOT DUPLICATE.