My Asthma Symptom Diary

Keep track of symptoms with the chart below. (Make some copies first.) Show your records to your healthcare provider at your visits. As your asthma control improves you should have fewer episodes of symptoms to record.

 

Date

Symptoms

Possible triggers

Action taken

Results

Did symptoms interfere with your sleep? Yes or No?

 

3/3

Example:

Wheezing, peak flow 75%

 

Cold air

 

2 puffs albuterol, went inside

 

Symptoms gone in 20 min.

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was this helpful?

Yes No
 

Tell us more.

Check all that apply.
 
 
 
 
 
NEXT ▶

Last question: How confident are you filling out medical forms by yourself?

Not at all A little Somewhat Quite a bit Extremely

Thank You!

© 2000-2017 The StayWell Company, LLC. 780 Township Line Road, Yardley, PA 19067. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.