Dd Form 2792 - Family Member Medical Summary (With Instructions) (Page 10 of 13) in pdf

FAMILY MEMBER/PATIENT NAME (Last, First, Middle Initial)

SPONSOR NAME

SPONSOR SSN (Last four)

ADDENDUM 1 - ASTHMA/REACTIVE AIRWAY DISEASE SUMMARY:

To be completed by a Qualified Medical Professional

Complete addendum if patient has been evaluated or treated for asthma within the past five years.

1. DIAGNOSTIC DESCRIPTION CODE (ICD-9-CM or, when approved, ICD-10-CM)

2. MEDICATION HISTORY

a. MEDICATION(S)

b. DOSAGE

c. FREQUENCY

3. HISTORY ASSOCIATED WITH ASTHMA ATTACKS (X as applicable)

YES

a. ARE THERE ANY TRIGGERS FOR THE PATIENT'S ASTHMA ATTACKS (stress, environment, exercise)?

b. DOES THE PATIENT ROUTINELY (greater than 10 days per month/four months per year) USE INHALED ANTI-INFLAMMATORY AGENTS AND/OR

BRONCHODILATORS?

c. HAS THE PATIENT TAKEN ORAL STEROIDS DURING THE PAST YEAR (prednisone, prednisolone)?

IF "YES", NUMBER OF DAYS IN PAST YEAR:

d. HAS THE PATIENT EVER EXPERIENCED UNCONSCIOUSNESS OR SEIZURES ASSOCIATED WITH ASTHMA ATTACKS?

e. HAS THE PATIENT REQUIRED AN URGENT VISIT TO THE ER OR CLINIC FOR ACUTE ASTHMA DURING THE PAST YEAR?

IF "YES", INDICATE THE NUMBER OF VISITS IN THE PAST YEAR:

f. HAS THE PATIENT BEEN HOSPITALIZED FOR PULMONARY DISEASE (pneumonia, bronchitis, bronchiolitis, croup, RSV) DURING THE

PAST YEAR? IF "YES", INDICATE THE DATE(S) OF HOSPITALIZATION (YYYYMMDD):

g. DOES THE PATIENT HAVE A HISTORY OF ONE OR MORE HOSPITALIZATIONS FOR ASTHMA RELATED CONDITIONS WITHIN THE PAST FIVE

YEARS? IF "YES", HOW MANY?

INDICATE DATE OF LAST ADMISSION (YYYYMMDD):

h. HAS THE PATIENT REQUIRED MECHANICAL VENTILATION (Intubation/use of respirator) DURING THE PAST 3 YEARS?

i. DOES THE PATIENT HAVE A HISTORY OF INTENSIVE CARE ADMISSIONS?

j. APPROXIMATE NUMBER OF DAYS THAT THE PATIENT MISSED SCHOOL/WORK/PLAY DUE TO ASTHMA-RELATED PROBLEMS (including visits to physicians)

DURING THE PAST YEAR?

k. HOW OFTEN DOES THE PATIENT USE HIS/HER RESCUE INHALER OR NEBULIZER MEDICATION (such as Albuterol or Levalbuterol) FOR INCREASED OR

ACUTE SYMPTOMS?

4. SEVERITY LEVEL. What is the patient's severity level based on the current treatment plan? (Select one level of severity. Definitions are

examples of severity. Pulmonary function tests are required only if clinically indicated.)

a. INTERMITTENT ASTHMA . Intermittent symptoms

1 time per week. Brief exacerbations (from a few hours to a few days). Nighttime asthma symptoms <2

times a month. Asymptomatic and normal lung function between exacerbations. PEF or FEV1

80% predicted; variability <20%.

b. MILD PERSISTENT ASTHMA. Symptoms

2 times a week but <1 time per day. Exacerbations may affect sleep and activity. Nighttime asthma symptoms >2

times a month. PEF or FEV1

80% predicted; variability 20 - 30%.

c. MODERATE PERSISTENT. Symptoms daily. Exacerbations affect sleep and activity. Nighttime asthma >1 time a week. Daily use of inhaled short-acting B2

agonist. PEF or FEV1

60% and 80% predicted; variability > 30%.

d. SEVERE PERSISTENT. Continuous symptoms. Frequent exacerbations. Frequent nighttime asthma symptoms. Physical activities limited by asthma

symptoms. PEF or FEV1 <60% predicted; variability > 30%.

5.a. PROVIDER PRINTED NAME OR STAMP

b. SIGNATURE

c. DATE (YYYYMMDD)

d. TELEPHONE NUMBERS (Include Area Code/Country Code)

e. OFFICIAL E-MAIL ADDRESS

f. MEDICAL SPECIALTY

(1) COMMERCIAL

(2) DSN (Military only)

DD FORM 2792 (ADDENDUM 1), AUG 2014

Page 8 of 11 Pages

Dd Form 2792 - Family Member Medical Summary (With Instructions) Page 10

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