Asthma Diary

ASTHMA DIARY FORM click here pdf form for printing

How to use your Asthma Diary:

Date: Begin your diary the day it is received.

Early Warning Signs (Clues): Place a  in the box if any of these signs occurred.

*Symptom Score

0 = None
1 = Barely Present
2 = Obviously Present
3 = Interferes with Activity

Asthma Out of Control: Place a √ in the box if any of the listed signs occurred.

Medicine: List all the asthma medicines used (eg. Ventolin 2 puffs as needed). Use one √ for each puff of medicine.

Caregivers Notes: List your child’s activities and possible asthma triggers on the days where your child had early warning signs or symptoms. Also, list any questions or concerns to be discussed with your doctor.

Common Asthma Triggers:

Colds, animals, pollens, outdoor molds, dust mites, cigarette smoke, cold air, irritants (strong smells, smoke, dust) and exercise.