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Date of last visit:[text]

Current Controller:[checkbox name="ICS" value=" NO controller medication/s|Flovent HFA 44 mcg|Flovent HFA 110 mcg|Asmanex HFA 100 mcg|Asmanex HFA 200 mcg|Symbicort 80/4.5 mcg|Symbicort 160/4.5 mcg|Advair HFA 45/21 mcg|Advair HFA 115/21 mcg|Pulmicort 0.25mg|Pulmicort 0.5mg"]
Dose:[checkbox name="dose" value="2 puffs twice daily| 2 puffs once daily| 1 unit nebulized twice daily| 1 unit nebulized once daily| 1 puff twice daily| 1 puff once daily"]

Leukotriene Receptor Antagonist:[checkbox name="Monteleukast" value=" None| Monteleukast (Singulair) 4mg daily| Monteleukast (Singulair) 5mg daily| Monteleukast (Singulair) 10mg daily"][text]

Spacer Use for Metered Dose Inhalers:[checkbox name="Spacer_use" value=" Spacer is always used| Spacer is often used (but not always)| Spacer is only used sometimes| Does not use spacer at all| Not Applicable"][text]
Spacer Technique:[checkbox name="spacertechnique" value=" Describes appropriate technique| Demonstrates appropriate technique|Poor technique|Not applicable"]

Medication Adherence
Average frequency of missed doses of controller medication (approximate):[checkbox name="misseddose" value=" 0 (never misses a dose)|1-2 days/week|3-4 days/week|5-7 days/week"]

Allergy Medications
Nasal Spray:[checkbox name="allergymeds" value=" none| Flonase| Dymista| Astelin| Nasonex| Other:"] [text]
Frequency of use:[checkbox name="Allergymeduse" value=" Daily| As needed"]
Oral Antihistamines:[checkbox name="POantihistamines" value=" none| Cetirizine (Zyrtec)| Loratadine (Claritin)| Fexofenadine (Allegra) |Diphenhydramine (Benadryl)"]
Frequency of use:[checkbox name="POantihistaminefrequency" value=" Daily| As needed"]
Comment/s: [text]

Recent Asthma Control (past 4 weeks):
Day time symptoms:[checkbox name="daytimesx" value="none| < 1x/week| 1 to 2x/week| > 2 x/week"]
Nocturnal symptoms:[checkbox name="nighttimesx" value=" none| 1 to 2x/ month| > 2x/month"]
Rescue inhaler use:[checkbox name="albuteroluse" value=" none| once a week or less| 1-2x/week week| almost daily| 1-2x/day| >3x/day"]

Exercise-induced symptoms:[checkbox name="exercisesx" value=" none| present only when sick, otherwise no limitations when well| sometimes present even when well| always present even when well| frequent symptoms that interfere with activities of daily living| daily symptoms that interfere with activities of daily living"]

Exacerbations since last seen by Pediatric Pulmonology
ER/Urgent Care visits:[text]
ICU admissions:[text]
Outpatient sick visits:[text]
Systemic steroid burst/s:[text]
Other/s:[text]
[checkbox name="recentexacerbation" value="No exacerbations since last visit|Most recent exacerbation was"][text]

Usual Asthma Symptoms:[checkbox name="symptoms" value="cough| wheezing| shortness of breath| chest tightness| chest congestion| nighttime awakening| no symptoms related to asthma"]
Symptom Pattern:[checkbox name="pattern" value="year-round| seasonal| episodic| non-specific/random"] [text]
Trigger/s:[checkbox name="triggers" value="no specific trigger| dust| URI/colds| mold| dust mites| cockroach| animal dander| pollen| smoke exposure| changes in weather| activity (e.g., playing, exercise)"] [text]

Allergy Symptoms:[checkbox name="Allergysx" value="none|runny nose|nasal congestion|sneezing|nasal itching|mouth breathing|postnasal drip|loss of taste|facial pressure or pain|itchy, watery eyes|eye swelling|sore throat|hoarseness|congestion or popping of the ears|itching of the throat or ears|frequent awakening or difficulty falling asleep"]
Date of last visit:

Current Controller:
Dose:

Leukotriene Receptor Antagonist:

Spacer Use for Metered Dose Inhalers:
Spacer Technique:

Medication Adherence
Average frequency of missed doses of controller medication (approximate):

Allergy Medications
Nasal Spray:
Frequency of use:
Oral Antihistamines:
Frequency of use:
Comment/s:

Recent Asthma Control (past 4 weeks):
Day time symptoms:
Nocturnal symptoms:
Rescue inhaler use:

Exercise-induced symptoms:

Exacerbations since last seen by Pediatric Pulmonology
ER/Urgent Care visits:
ICU admissions:
Outpatient sick visits:
Systemic steroid burst/s:
Other/s:


Usual Asthma Symptoms:
Symptom Pattern:
Trigger/s:

Allergy Symptoms:
Result - Copy and paste this output: