Please help our practice improve the care we provide your child with asthma. Our goal is for your child to be symptom free, sleep well and participate in all activities. Your nurse or doctor will review these questions with you.
SYM-------------------------------------------------------------------------------------------------------------------------------SYM
In the past 4 weeks how frequently has your child:
QUA-------------------------------------------------------------------------------------------------------------------------------QUA
SEV--------------------------------------------------------------------------------------------------------------------------------SEV
In the past 12 months was your child:
TIM----------------------------------------------------------------------------------------------------------------------------------TIM
CON-------------------------------------------------------------------------------------------------------------------------------CON
During the past month is your child taking any DAILY control medicines for Asthma or Allergic Rhinitis (Atopy)?
MOD------------------------------------------------------------------------------------------------------------------------------MOD
Previously we treated your child for asthma symptoms.
During the past 12 months has your child:
If yes to any of these questions, then please complete the form on the other side.
If no, then return this form to the nurse.
Thank you!
Your information will be encrypted.