Asthma Management Initial Assessment Form
ADVERTISEMENT
1ASTHMA MANAGEMENT
NAME______________________________ DATE __________
Initial Assessment
DOB_______________ID#________________
For use by the clinician to guide the assessment of a child with symptoms suggestive of asthma
HISTORY:
1. Symptoms
___Daytime cough
___Daytime wheezing
___SOB
___Chest tightness
___Sputum production
___Nighttime cough
___Nighttime wheezing
___Interrupted sleep due to symptoms
2. Patterns of Symptoms
___Perennial, seasonal, or both_______________________________________________________
___Continual, episodic, or both _______________________________________________________
___Onset, duration, frequency (# of days or nights per week or month)________________________
___Diurnal variations, esp. nocturnal & on awakening in early morning ________________________
3. Precipitating and/or aggravating factors
___Viral respiratory infections
___Environmental allergens
(indoors/outdoors)
___Exercise
___Irritants
(tobacco smoke, strong odors, chemicals)
___Changes in weather, exposure to cold air
___Animal dander or feathers
___Foods, food additives, food preservatives
___Emotional expression
(fear/anger/crying/laughing)
___Drugs
(aspirin, NSAIDs, beta-blockers including eye drops, others)
___Other__________________________________________________________________________________
4. Development of disease and management/treatment
Age of onset and diagnosis__________________________________________________________
Use of peak flow meter (frequency, current readings)______________________________________
Present medications________________________________________________________________
_____________________________________________________________________________
Need for oral corticosteroids and frequency of use________________________________________
Episodes of unscheduled care:
Hospitalization____________________________________________________________________
Emergency Room_________________________________________________________________
Urgent Care Clinic_________________________________________________________________
Life-threatening exacerbations:
Intubation______________________________ICU admission______________________________
Typical exacerbation: Frequency______________________________________________________
Usual prodromal signs/symptoms_____________________________________________________
Usual patterns and management (what works?)__________________________________________
_______________________________________________________________________________
Number of days missed from school (parents from work) due to asthma symptoms_______________
Limitations of activity________________________________________________________________
Effect on growth, development, school__________________________________________________
5. Social history (of the student/family)
Home environment_________________________________________________________________
Members of household______________________________________________________________
_____________________________________________________________________________
Family members with health problems__________________________________________________
_____________________________________________________________________________
Smoking in the home_______________________________________________________________
Substance abuse__________________________________________________________________
Social support/network______________________________________________________________
Education level (parents)________________________Employment__________________________
Health insurance coverage___________________________________________________________
Economic impact of asthma on the family________________________________________________
Pt/Family perception of asthma________________________________________________________
Signature (staff)___________________________________Date__________________
Referral: __________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life