Asthma Assessment Form printable pdf download

Child’s Name:________________________________________________________________

Child’s Date of Birth:_______________________________________________________

Child’s Age:___________________________________________________________________

Asthma Assessment Form

Please complete the following form regarding your child’s asthma. This will help us better understand and

effectively treat your child’s asthma.

1. Ethnic Background:

American Indian

Asian/Hawaiian/Pacific Islands

Black/African American

Caucasian

Hispanic

Other:________________________________________________________

2. What concerns you the most about your child’s asthma?

__________________________________________________________________________________________________________________________

3. How does asthma affect family routine and activities?

__________________________________________________________________________________________________________________________

4. Please list all medications at home that your child IS currently taking (Include creams, inhalers, nasal

sprays):

__________________________________________________________________________________________________________________________

5. Please all medications at home that your child IS NOT currently taking (Include creams, inhalers, nasal

sprays):

________________________________________________________________________________________________________________________

6. Which type of device(s) is currently used to administer your child’s medications? (Select all that apply)

Nebulizer:

with a facemask

with the mouthpiece Is child cooperative?

Yes

Spacer:

with a facemask

without a facemask

Is child cooperative?

Yes

Inhaler alone, we do not use a spacer or valved holding chamber.

Asthma Assessment Form