Last Initial 
First Initial 
Age 
Date of Visit 
Date of Last Visit 
PCP 

SINCE MY LAST VISIT

How would you describe your asthma?0 Unknown1 Rarely noticed2 Mild3 Moderate4 Severe

Is it 0 Unknown1 Getting better2 Getting worse3 Stable

Do you feel that asthma has impaired your ability to? (mark all that apply)
Go to school
Keep up with day-to-day activities
Full particiaption in physical activities
Normal day-to-day activities missed because of asthma
Work missed be parents because of asthma

Times per week that you have had symptoms of asthma (wheezing, cough, SOB, chest tightness) 

Times per month that you have been waking up during the might dur to astham symptoms 

Doctor visits because of asthma 

ER visits 

Hospital days 

ICU visits 

Did patient bring in peak flow records? 0 No1 Yes2 Unknown 

I have used my peak flow meter 0 N/A1 Daily2 With symptoms3 Not at all4 Other 

My peak flow has been running between  and 

Please check all the medication classes that the patient is on and answer accompanying questions
short acting beta agonists (albuterol, Xopenex)
long acting beta agonists (Serevent)
inhaled steriods (Flovent, Pulmolcort)
                                        How often is the patient using the medication 0 N/A1 all the time (100%)2 most of the time (80-99%)3 some of the time (50-79%)4 occassionally (30-49%)5 rarely (0-29%) 
inhaled anti-inflammatories (Intal, Tildate)
                                        How often is the patient using the medication 0 N/A1 all the time (100%)2 most of the time (80-99%)3 some of the time (50-79%)4 occassionally (30-49%)5 rarely (0-29%) 
leukotriene inhibitors
oral steriods        Has the patinet used the oral steriods? (check if yes)
intra-nasal medications
oral decongestants and antihistamines
antibiotics
anti-reflux

This page was designed and is maintained by David Kaelber, MD/PhD, Internal Medicine/Pediatrics (dck3@po.cwru.edu). (last updated 7 April 2001)