Assessment: Provider

1. Assessment of Asthma tool kit
1. Do you have daytime asthma symptoms (wheezing, coughing, shortness of
breath, chest tightness or pain) or use your albuterol inhaler or nebulizer? Not at
all (0 point), less than 2 times per week (1 point), greater than 2 x per week (2
points)
2. Do you have nighttime asthma symptoms (wheezing, coughing, shortness of
breath, chest tightness or pain), or use your albuterol inhaler or nebulizer? Not at
all (0 points), less than 2 times per week (1 points), greater than 2 x per week (2
points)
3. Do you have symptoms of wheezing, coughing, or difficulty breathing with
activity or exercise? Yes (2 points), No (0 points)
4. Do you have asthma symptoms or use your albuterol inhaler or nebulizer
during an acute illness for greater than 2 weeks? Yes (2 points), No (0 points)
5. Have you had an episode of asthma which required medical attention at an
urgent care or emergency room over the past 6 months? Yes (2 points), No (0
points)
6. How many school days did you miss due to asthma related illnesses in the
past year? None at all (0 points), 1-3 (1 point), 4-7 (2 points), greater than 8 (3
points)
Asthma Visit Information
Last spirometry date:
Baseline peak flow during the past year:
Highest Peak flow in past 6 months:
Lowest peak flow in past 6 months:
ER visit for asthma over past year:
Hospitalization for asthma over past year:
Number of albuterol refills over the past year:
Pet exposure:
Asthma triggers:
What are your early warning signs asthma: