Asthma Questionnaire

Please correct the errors described below.

Current Medications: List or attach all medications taken routinely or on an as needed basis.

Add Additional Medication

Past Medications used for Allergy and Asthma (include oral and topical corticosteroids, antihistamines, inhalers and nose sprays)

Add Additional Medication

Allergies: include drug allergies, insects, environmental

Add Additional Allergies

Hospitalizations or ER visits in the past 5 years?

Add Additional Hospitalization

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