Fremont Community Health Services
Patient Label
ASTHMA MANAGEMENT VISIT
Visit Date:
Follow-Up
Initial
Current Visit
CONCERNS:
Provider review & initials:
VITALS: Ht
ROS: HEENT
Wt
Respiratory
BMI
BP
Allergy symptoms
/
Cardiovascular
/wk Nighttime
# of ED visits last 6 months
Prednisone bursts since last visit?
Pets in home?
Classification
Severe Persistent
Moderate Persistent
Mild Persistent
Mild Intermittent
Medications: Chart updated
Day: coughing, wheezing,
SOB or chest tightness?
All the time
Daily
3 - 6 / week
< 2 / week
Tobacco Use / Exposure: Y N
Amount:
Advised to quit?
Y N
Allergies
P
R
O2 Sat
T
Symptom Frequency: Daytime
Skin
/wk Albuterol use
Abdomen
Other
Asthma Control Test Score
Triggers
Changes
Night: coughing, wheezing,
SOB, or chest tightness?
Frequent
> 5 / month
3 - 4 / month
< 2 / month
Diagnosis Yr
Refills needed:
Symptoms with activity
FEV1/PEF
Interferes with any activity
Interferes with mod activity
Only with a lot of activity
Not at all unless an attack
FEV1/PEF < 60%
FEV1/PEF > 60%
FEV1/PEF > 80%
FEV1/PEF > 80%
predicted
< 80% predicted
predicted
predicted
Physical Exam
Constitutional:
Eyes:
ENT:
CV:
Skin:
[
[
[
[
[
[
[ ]·General Appearance
[ ]·Vitals (initial above)
]·Conjunctiva and lids
]·Canals / TMs
]·Nose
]·Tonsils / Pharynx / Nodes
]·Auscultation (Rhythm / S1 , S2 / Murmur)
]·Inspect
Assessment
1. Asthma Control:
Severity:
Intermittent
Well-controlled
Mild persistent
Respiratory: [ ]·Effort [ ]·Auscultation
[ ]·Post-neb. Auscultation:
Clinical Interventions: [ ]· Nebulizer treatment
[ ]· 1.25 / 3 ml given
(initials)
[ ]· 2.5 / 3 ml given
(initials)
[ ]· O2 Sat post-neb.
[ ]·Spirometry Results
Pre- / Post-bronchodilation
Not well-controlled
Moderate persistent
Poorly controlled
Severe persistent
2. Other:
Plan Medications:
Smoking cessation resources given:
Immunizations
Pneumovax
Influenza
Other
Refer to asthma education
Refer to pulmonology
Asthma Action Plan updated/reviewed:
Has spacer or spacer provided:
Labs
Other Orders
Next appointment
Self-Management Goal
Signature
Teaching topics
Needed
General info/asthma
Smoking/Environment
Peak Flow/Monitoring
Use of MDI and Spacer
Asthma Action Plan
Partnering with school/daycare
Safety/Developmental
Other
Done