Asthma data collection form

WEST SIDE PEDIATRICS ASTHMA DATA COLLECTION FORM 2009
Remove because _____________________________ New Patient Name: _____________________________________ Date of Birth: ____/____/____ Date of Visit: ____/____/____
Insurance Company: ________________________________
Provider: DePalma Esterle Gibbons Maamari Hunter Maddiwar Raterman Ref# _______________
PARENT SECTION - Please Complete Questions 1-12 Thank you for helping us care for your child.
1. How many days of school/daycare has your child missed due to asthma in the past 6 months? ____ # of days
2. How many work days have you or your spouse missed due to your child’s asthma in the past 6 months? ____ # of days
3. Has your child visited the Emergency Room or Urgent Care Center due to asthma in the past 12 months? YES NO
4. Has your child been admitted to the hospital due to asthma in the past 12 months? YES NO
5. How comfortable are you in your ability to manage your child’s asthma, rated on a scale of 1-10? (Please circle) Not Comfortable = 1 2 3 4 5 6 7 8 9 10 = Very Comfortable 6. During the past month, how frequently has your child experienced episodes of cough, shortness of breath, wheezing or reduced activity
due to asthma during the DAY?
7. During the past month, how frequently has your child experienced episodes of cough, shortness of breath, wheezing or waking up
due to asthma at NIGHT?
7 or more nights per month 5-6 nights per month 3-4 nights per month 0-2 nights per month 8. During the past week, how often did your child use a fast acting or quick relief medication, at times other than before exercise? (includes
Albuterol, Ventolin®, Proventil®, Xopenex®) not at all less than 1 time per day 1-3 times per day 4 or more times per day not sure 9. When are asthma symptoms worse? (Check all that apply)
10. How often does asthma limit your child’s activities? some of the time most of the time all of the time 11. How would you rate your child’s asthma control during the past month?
somewhat controlled well controlled completely controlled 12. Are you planning to get a flu shot for your child? Already Received shot date: ___/___/_____ PHYSICIAN SECTION – Please Complete Questions 13-20
13. Asthma severity level: Severe Persistent Moderate Persistent Mild Persistent Mild Intermittent 14. Is the patient on a controller medication? 15. If YES, does the patient/parent report using controller medications daily?
16. For patients who use rescue/controller inhalers, is a spacer utilized? (Maxair® and dry powder inhalers do not require spacer) 17. Has the patient received oral steroids for bronchospasm within the past 12 months?
18. Does the family have a copy of a written asthma management plan from a primary care physician or specialist? If YES, please review with family and update, as needed. 19. Has the patient been seen by an allergist or pulmonologist during the last 12 months for assistance with asthma management due to
severity of illness? Specialist: ____________________________ 20. How would you rate the patient’s asthma control during the past month?
somewhat controlled well controlled completely controlled*
*Complete or total control of asthma is defined as no asthma symptoms; no rescue bronchodilator use; no nighttime or early morning
awakening; no limitations on exercise, work or school; complete control of asthma by patient and physician assessment; and normal or
personal best PEF or FEV1. (Joint Task Force on Practice Parameters for Allergy & Immunology – AAAI, ACAI, pub. Nov. 2005)
Follow-up visit: Return in: _____ weeks, or _____ months
(Return visit date: _____ / _____ / _____)

Source: http://westsidepedscincy.com/files/forms/2009_Asthma_Sheet.pdf