MHMC PACT Follow-up Clinic Visit

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 asthma has impaired my ability to
	Go to school:	   		[school]
	Keep up with activities:	[DTDactivities]
	Physical activities:		[physical]
	Day-to-day activities missed:	[ADLmissed]
	Parents' missed work:		[work]

Symptoms per week:			[week]

Awoken with symptoms per month:	[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 Beta agonists:	[saba]
	Long-acting Beta agonists:	[laba]
	Inhaled steroids:			[isteroids]
		Use:				[isteroidsuse]
	Inhaled anti-inflamatory:	[iai]
		Use:				[iaiuse]
	Leukoteine Inhibitors:		[li]
	Oral steroids:			[osteroids]
	Intra-nasal medications:	[inm]
	Oral decon./anti-hist.:		[odah]
	Antibiotics:			[ab]
	Anti-reflux:			[ar]

If you have any questions about this record, please contact David Kaelber,
MD/PhD at dck3@po.cwru.edu.