Asthma Visit Patient Information Form

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ASTHMA VISIT
Name:
Date:
Child’s Age:
History
Type of Visit
[ ] Sick [ ] Well
[ ] Follow-up
Chief Complaint: _____________________________
Sick Visit History:
School/daycare days missed (last 12 months): __________
[ ] Exacerbation
Parents’ missed work days (last 12 months): _________
Day-time wheezing (# days/wk): _________
Night-time symptoms (# nights/wk): _________
Wheezing with play/exercise
Always:___ Sometimes:___ None:___
Albuterol use (# days/wk): ________
Current Medications
ER visits/hospitalizations: _________
Tobacco exposure: Y___ N ___
Medication
Eczema: Y___ N ___
Nasal Sx: _____
Dosage
Route
School
School: __________________ Phone # ___________
Compliance
School nurse: __________
Freq
Rescue inhaler at school?
___Y
____N
Route
PE/Recess activity problems?
___Y
____N
Explain:
1
# days/week needing prn albuterol at school: ______
Asthma Action Plan at school? ___Y
____N
2
Peak flow meter at school?
___Y
____N
3
Other ______________________________________
4
Physical Exam
Peak flow:
Ht: _____ Wt: ______
______ Predicted:______ Personal best: ________
Temp: ______ HR: _______ RR: _______
Pulse ox
Spirometry
: ______
: ______
General: _____________________________________
HEENT TM: _____________Nose: _________
In-Office Interventions
Throat: __________
Treatment
Wheeze
Air exchange
O
sat
2
Lungs: _______________
CV: _____________
Abd: _______________
Skin: ____________
[ ] Steroids _____________
Other:
[ ] Other _____________
Impression
Asthma Classification
[ ] Mild intermittent
[ ] Mild persistent
[ ] Moderate persistent
[ ] Severe persistent
Other diagnosis ___________________
Education
[ ] Inhaler
[ ] Spacer [ ] Peak flow [ ] Environment [ ] Smoking cessation referral
[ ]
Flu shot
Additional Clinical Note
[ ] Referral to allergist/asthma specialist
Written Action Plan
Other School Forms
Parent permission to interact with school?
[ ] Initial action plan given
__ Inhaler prn at school
Yes___ No___
[ ] Plan updated
__ Inhaler pre-physical activity at school
[ ] Discussed with patient
__ Carry inhaler on person
If yes, Date of permission: ________
[ ] Copy given to patient
[ ] Copy given to parent
[ ] Copy given to/for school
This form may be duplicated or changed to suit your needs and your patients’ needs.

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