Asthma History Form

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Texas State University-San Marcos
Student Health Center
601 University Dr., San Marcos, TX 78666
Ph. (512) 245-2161 Fax (512) 245-9288
ASTHMA HISTORY
Date ____________
Name_____________________________ DOB ___________ PLID# __________________________
1. When were you first diagnosed with asthma?
Month__________ Year____________
2. Last asthma episode? _______________
How many episodes in the last year? ________________
Any ER visits? Yes / No
Hospitalized? Yes / No
Ever had a breathing tube put in for asthma? Yes / No
3. Put an X next to the best description of your asthma symptoms before treatment was first begun:
____ Continual symptoms; limited physical activity; frequent asthma attacks; frequent nighttime symptoms
____ Daily symptoms & use of “rescue inhaler”, asthma affects activity/occurs 2 or more times/week; may last
days; nighttime symptoms over 5 X month
____ Symptoms more than 2 X week, but less than 1 X day; asthma may affect activities; night time symptoms
3-4 X month
____ Symptoms less than 2 X week; no symptoms & normal peak flow between attacks; nighttime <2 X month
4. List Medications used for asthma below:
How often do you use each?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
5. Does the medication control your asthma? Yes / No / Sometimes
6. What worsens your asthma? Exercise / Pollens / Smoke / Colds / Animals / Other _______________
7. Do you smoke?
If yes, _________ cigs./ cigars/ day. Use other tobacco products? _________
Yes / No
Are you constantly around someone who smokes?
____________________________
Yes / No
8. Does asthma limit any activity?
If so, how often? _________________________________
Yes / No
9. Do you use a Peak flow meter?
Spacer?
Yes / No
Yes / No
If so, brand (s)________________________________ last used? _________________________
10. How many times in the last year were you given steroids, injections or pills? ___________________
11. Have you ever seen an asthma specialist?
When? _____________ Where? ____________
Yes / No
12. When was the date of your last asthma checkup? ___________________
13. Have you ever received specific education on asthma?
When? _____________________
Yes / No
14. Who currently treats your asthma? _____________________________________________________
Name
Address
Phone
Reviewed by _____________________________________________________
Date ________________
Provider / title
Approved 07/30/02
Web 04/08/04

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