Annual ADULT ASTHMA PATIENT CARE FLOW SHEET

VISIT 1: INITIAL ASSESSMENT AND DIAGNOSIS

Patient Name: _________________________ Date: _________________________________ Influenza Vaccination date (last 2 years):
___________ &___________
Date of Birth: __________________________ Height _________ Weight _________BMI _______

DIAGNOSIS
History  History of atopic disorder  Current smoker
 Family history of asthma/atopic disorder  Former smoker
 Allergies  Second-hand exposure to tobacco smoke
 Oral corticosteroid (date) __________  ER visit (date) __________
Exacerbation  Hospitalization (date)___________  ICU ever? ______ (date if known) __________
History
 Wheeze Symptoms worse at night  early morning 
Current  Breathlessness Symptoms in response to exercise allergens cold air
Symptoms  Chest tightness Symptoms after taking aspirin  beta blockers
(last few days)  Cough

Comorbidities  COPD  Allergic rhinitis/sinusitis  Sleep apnea

 GERD  Laryngeal dysfunction  Nasal Polyps

 Occupational sensitizers: ____________  House dust mites

 Cats  Dogs  Infections (predominantly viral)
 Cigarette smoke  Mould
Environmental
Triggers  Cockroaches  Pollens
 Cold Air  Rhinovirus
 Dust  Season: ___________________
 Exercise  Other: _____________________

 YES  NO If yes, how was diagnosis confirmed:

Asthma  Spirometry  PEF
Diagnosis  Challenge test(s)  Confirmed by specialist/other physician
Confirmed

COMPLETE THE FOLLOWING SECTION IF DIAGNOSIS OF ASTHMA CONFIRMED

Controllers (Daily) Combination & Long-acting Quick Relievers (Rescue) Controller / Reliever
Relievers (Daily) (Daily+rescue in single Inhaler)
Inhaled:  Airomir MDI
 Alvesco MDI  Advair Diskus  Symbicort Turbuhaler
 Flovent MDI  Bricanyl Turbuhaler
 Advair MDI Other Medications
 Flovent Diskus  Oxeze Turbuhaler
Medication
 Qvar MDI  Oxeze Turbuhaler
 Nasal steroids _________
Prescribed at
 Pulmicort  Ventolin Diskus
this Visit  Serevent Diskus
 Prednisone (dose)______
Turbuhaler  Ventolin MDI
 Symbicort  Xolair
Oral:
 Singulair Turbuhaler  Other ____________
 Accolate

Dose:
Written Action  YES  NO Examples., www.AsthmaActionPlan.com
Plan Provided www.on.lung.ca

Education  Chronic nature of disease/adherence  Avoidance of triggers

Provided at this
Visit
 Inhaler technique  Smoking cessation , If yes:
 Medications http://www.omacti.org/new_fee_code_cessation.pdf
(Ontario only)
 Certified asthma educator  Pediatrician
Referral(s)
 Asthma Education Program  Respirologist
 Allergist  For diagnostics________________
 Nurse Educator

Follow-up ( ______ weeks ________ months ________plan

FOR SUBSEQUENT VISITS,
PLEASE USE ASTHMA FLOW SHEET FOR POST-DIAGNOSIS FOLLOW-UPVISITS 2 AND 3