El Camino Pediatrics

To print: Click here or Select File and then Print from your browser's menu

El Camino Pediatrics: Asthma Screening


Name: ____________________________	Date: _______________
Primary Doctor: ____________________	DOB: ________________
Insurance: __________________________ HMO PPO

A FEW QUESTIONS ABOUT YOUR ASTHMA… Parents, please answer for your children who are too young to complete this themselves!
Overall, how is your asthma? About the same Better than usual Worse than usual During the past month, has your asthma caused you to miss school or other activities? Yes No How many days?________ During the last month, have you woken up at night because of wheezing, coughing or other asthma symptoms? Yes No How many nights? ________ Over the past 3 months, have you gone to the emergency room, urgent care, or urgent office visit because of your asthma? Yes No	How often would you say you use your rescue inhaler (albuterol or Xoponex)? More than once a day Once a day 2-3 times a week Occasionally Do you have a peak flow meter? Yes No I don’t know Have you been taught, and do you understand how to use your asthma medications? Yes No Do you know what can trigger asthma and what you can do to prevent an asthma attack? Yes No Do you have a written asthma action plan? Yes No