HUMBLE INDEPENDENT SCHOOL DISTRICT
HEALTH SERVICES
Asthma Health History/Assessment Form
Date:
Campus:
Student Name:
Parent/Guardian:
Work Phone:
Allergist:
Student ID:
Home Phone:
Cell Phone:
Phone:
1.
Does your child have a diagnosis of asthma from a healthcare provider:
2.
History of Current Status
Exercise
Animals
Respiratory Infection
Foods
Change in Temperature
Odor/Fumes
Vapors ________
Molds
Pollens
Dust
Other:
________________________________________
Yes
d. Date of last asthma episode:
e. Symptoms:
f. Are the asthma episodes:
Same
Better
Worse
Trigger and Symptoms
a. What are the early signs and symptoms of your student’s asthma episodes? (Be specific; include things the
student might say.)
b.
c.
d.
How does your child communicate his/her symptoms?
How quickly do symptoms appear after trigger:
secs.
Please check the symptoms that your child has experienced in the past:
General
Trouble Sleeping caused
by coughing, SOB, Wheezing
Frequent Respiratory
Infections
Delayed recovery of
Bronchitis episodes
Limited exercised because
of Shortness of Breath
Fatigue
4.
No
b. Age of student when asthma first diagnosed:
c. How many times has student had an asthma episode:
Once
More than once,
Hospitalized
a. What are your child’s triggers
3.
Date of Birth:
Abdominal
Throat
mins.
Lungs
Heart
Nausea
Itching
Shortness of breath
Vomiting
Tightness
Repetitive Cough
Frequent
Intermittent Cough
Whistling or Wheezing
when exhaling
Frequent cough
hrs.
Increase pulse
Loss of
Consciousness
Chest pain
Chest Congestion
Chest Tightness
Treatment
a. How has asthma been treated:
b. How effective was the student’s response to treatment?
c. Was there an emergency room visit?
No
Yes, explain:
d. Was the student admitted to the hospital?
No
Yes, explain:
e. What treatment or medication has your healthcare provider recommended for use in asthma treatment?
f. Has your healthcare provider provided you with a prescription for medication?
g. Have you used the treatment or medication?
No
No
Yes
Yes
days
h. Please describe any side effects or problems your child had in using the suggested treatment:
5.
6.
Self Care
a. Is your student able to monitor and prevent their asthma symptoms?
b. Does your student:
1. Know what triggers to avoid
2. Is your child able to communicate asthma symptoms
3. Tell an adult immediately after an exposure
5. Wear a medical alert bracelet, necklace, watchband
6. Tell peers and adults about the allergy
c. Does your child know how to use emergency medication?
d. Has your child ever administered their own emergency medication?
Family/Home
a. How do you feel that the whole family is coping with your student’s asthma?
b. Does your child carry an inhaler in the event of a reaction?
c. Has your child ever had to use a rescue inhaler?
d. Do you feel that your child needs assistance in coping with his/her asthma?
No
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
7.
General Health
a. How is your child’s general health other than asthma?
b. Does your child have other health conditions?
c. Hospitalizations?
e. Please add anything else you would like the school to know about your child’s health:
8.
Notes:
Parent/Guardian Signature:
Date:
Reviewed by:
Date: