Asthma Follow Up Questionnaire

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.

Visit Date

Severity Score

Patient Name

Date of Birth

Med Record #

Name of person completing history

Relationship to child

Type of Visit

SYM-------------------------------------------------------------------------------------------------------------------------------SYM

In the past 4 weeks how frequently has your child:

QUA-------------------------------------------------------------------------------------------------------------------------------QUA

SEV--------------------------------------------------------------------------------------------------------------------------------SEV

In the past 12 months was your child:

a) Admitted to a hospital for asthma?

Yes No

b) Treated at an ED or Urgent Care Center for asthma or breathing problems?

Yes No

c) Prescribed an Oral Steroid medicine (Prednisone, Orapred) for Asthma?

Yes No

d) Evaluated by an Allergist or pulmonologist?

Yes No

TIM----------------------------------------------------------------------------------------------------------------------------------TIM

How many days of school/daycare has your child missed due to asthma in the past 6 months?

How many work days did an adult miss due to your child’s asthma in the past 6 months?

CON-------------------------------------------------------------------------------------------------------------------------------CON

Do you have a written Asthma Action Plan?

Yes No

During the past month is your child taking any DAILY control medicines for Asthma or Allergic Rhinitis (Atopy)?

Add new row

Do you have a spacer?

Yes No

MOD------------------------------------------------------------------------------------------------------------------------------MOD

When are Asthma symptoms worse? Check all that apply

winter

spring

summer

fall

during exercise

If during exercise, used inhaler?

Yes No

In our effort to improve patient care, please read the following.

Previously we treated your child for asthma symptoms.

During the past 12 months has your child:

Coughed now and then for no good reason?
Coughed when laughing?
Coughed with aerobic exercise?
Taken any medicines using an inhaler (By mouth not nose) or a nebulizer?

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!

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