ࡱ> bda bjbjVV 7`<< \\8;4oWkkkkk~~~az~aakk!!!a8kk!a!!ky|bp'0W R  <~"!~~~L~~~Waaaa ~~~~~~~~~\ e:  Asthma Initial & Maintenance Form Patient Name: _____________________ Date: ______________________________________ Allergies Over the last 12 months how many of the following has the patient had r/t asthma?:Medication Therapy: ED visits _________Hospitalizations _________Peak Flow/SpirometrySchool days missed _________ Today in office Personal best or range _____ Visits to the doctor _________Lowest recently( Prescribed today ?Current Symptoms (please circle appropriate category in each column)  ClassificationDay: coughing, wheezing, SOB or chest tightness?Night: coughing, wheezing, SOB, or chest tightness?Symptoms with activity FEV1/PEF Severe PersistentAll the timeFrequentInterferes with any activityFEV1/PEF <60% predictedModerate PersistentDaily>5/monthInterferes with mod activityFEV1/PEF >60%<80% predMild Persistent3-6/week3-4/monthOnly with a lot of activityFEV1/PEF > 80%% predictedMild Intermittent< 2/week< 2/monthNot at all unless an attackFEV1/PEF >80% predicted Past Asthma History  EnvironmentAge first wheezed/diagnosed:( Trigger precipitating this visit(Premature(Smoking(Bronchopulmonary Dysplasia(Active (Passive(Previous referral to asthma specialist:(Pets(Skin testing:(Roaches(RAST testing:( Other(Eczema(Control measures implemented:Physical ExaminationWeight%ileHeight%ileBMI%ilePulseRRBPkgcmGeneral:Lungs:( Clear ( Wheezing ( Poor air movement I:E Ratio ( Normal ( Prolonged Retractions ( None ( Moderate ( Mild ( SevereENT: (Sinus tenderness Cardiac: Abdomen: GU: Muscoskeletal: Neuro: TeachingImmunizationsClassification of Current SeverityDoneVaccines due today? (yes ( no ( Severe Persistent ( Mild Persistent(General info about asthma ( ( Moderate Persistent ( Mild Intermittent(Smoking/Environment ((Peak Flow/Monitoring (Assessment( Use of MDI and Spacer (Need influenza vaccine? (yes ( noDoes current severity match current therapy? (Yes (No( Management Plan (Needs 2nd dose in 1 mo? 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HI9I8n[]^   @ `@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial;WingdingsSMonotype SortsSymbolA BCambria Math"h+f+f-=FB B 24d  3HX?^2!xxAsthma Encounter FormChildren's HospitalJeanette Oh+'0d    , 8DLT\Asthma Encounter FormChildren's HospitalNormal Jeanette2Microsoft Office Word@@NLk@B[|b@B[|bB ՜.+,D՜.+,P  hp  Children's Hospital  Asthma Encounter Form Title@@4_AdHocReviewCycleID_EmailSubject _AuthorEmail_AuthorEmailDisplayName_ReviewingToolsShownOnce(1lots of asthma stufflanderson@marshall.eduAnderson, Linda  !"#$%&'()*+,-./023456789:;<=>?ABCDEFGHIJKLMNOPRSTUVWXZ[\]^_`cRoot Entry F|beData 11Table@ WordDocument7`SummaryInformation(QDocumentSummaryInformation8YCompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q