Asthma Asessment Form Step 1 of 2 50% First Name*Last Name*Email* Date MM slash DD slash YYYY How many times do you have chest tightness, cough, shortness of breath or wheezing? None 2 or less times a week More than 2 times a week, but less than 1 time a day Daily More than 1 time a day Have you ever had allergy testing? Yes No How often does your doctor check your lung function by spirometry testing? At least every other year Only when I was diagnosed Never Date of last spirometry test MM slash DD slash YYYY Results of last spirometry test Normal Abnormal Have you ever been classified by your physician into one of the following groups? Intermittent Mild Persistent Moderate Persistent Severe Persistent What is your normal lung function as indicated by testing done by your doctor? Normal Abnormal Date of last test? MM slash DD slash YYYY Do you check peak flow readings at home? Yes No Do not have a meter How often do you use your quick-relief inhaler?How often do you use your quick-relief inhaler?2 times a month or lessMore than 2 times a month2 time a week1 time a weekDailyDo not have oneDo you have a written action plan to include the following components?(Check all that apply) Daily management description How to treat exacerbations When to seek emergency care Medication Plan Have you had any changes in your asthma medications? Yes No If yes, please list changesHave you achieved your current Asthma goal? Yes No What goal would you like to achieve for your asthma before our next contact?** All medical information will be kept confidential in accordance with HIPAA. Thank you for taking the time to complete the questionnaire. We wish you continued success on your Road To Wellness! NameThis field is for validation purposes and should be left unchanged. Δ