[place
 patient
 label
 here]

Last Name Initial:	[LastInitial]
First Name Initial:	[FirstInitial]
Visit Date:	[Visit]
Previous Visit Date:	[LastVisit]
PCP:	[PCP]
Describe your asthma	[describe1]
It is:	[describe2]
My astham has impaired	my ability to
Go to to school:	[school]
Keep up with activities:	[DTDactivities]
Physical	[physical]
Day-to-day	[ADLmissed]
Parents' missed work:	[work]
Symptoms per week	[week]
Awoken	[month]
Doctor visits:	[doctor]
ER visits:	[ER]
Hospital days:	[hospital]
ICU days:	[ICU]
Bring peak flow records?	[pfrecords]
Peak flow meter use:	[pfmeter]
Peak flow min:	[pfmin]
Peak flow max:	[pfmax]
Medications
Short-acting agonists	[saba]
Long-acting Beta agonists	[laba]
Inhaled steroids	[sisteroids]
Use:	[isteroidsuse]
Inhaled anit-inflamatory:	[iai]
Use:	[iaiuse]
Leukoteine Inhibitors:	[li]
Oral Steroids	[osteroids]
Intra-nasal medications	[inm]
Oral decon./anti-hist.:	[odah]
Antibiotics:	[ab]
Anti-reflux:	[ar]