Pulmonology
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Date of last visit: [text]

Current Management: Patient is on [checkbox name="field_controller" value="NO controller medication/s|Flovent 44|Flovent 110|Flovent 220|Symbicort 80|Symbicort 160|Advair HFA 45|Advair HFA 115| Pulmicort 0.25mg|Pulmicort 0.5mg|Advair Diskus 100|Advair Diskus 250"]- [checkbox name="field_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"]
[checkbox name="field_othermeds" value="Other medications:"] [checkbox name="field_singulairdose" value="Singulair 4mg daily|Singulair 5mg daily|Singulair 10mg daily"][text]

Spacer Use for Metered Dose Inhalers:
[checkbox name="Spacer_use" value="Spacer is used always|Spacer is often used (but not always)|Spacer is only used sometimes|Spacer is not used at all| Not Applicable"][text]

Spacer Technique:
[checkbox name="field_spacertechnique" value="Not applicable|Describes appropriate technique|Demonstrated appropriate technique"]

Medication Adherence:
Average frequency of missed doses of controller medication is about [checkbox name="field_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]
Oral Antihistamines: [checkbox name="POAntihistamines" value="Cetirizine (Zyrtec) | Fexofenadine (Allegra) | Levocetirizine (Xyzal) | Loratadine (Claritin, Alavert) "]

Recent Asthma Control (past 4 weeks):
Patient has had [checkbox name="field_daytimesx" value="no daytime symptoms|daytime symptoms once or twice a week|daytime symptoms more than twice in a week"].
Nocturnal symptoms [checkbox name="field_nighttimesx" value="- none at all|present once or twice a month|present more often than twice a month"].
Patient has [checkbox name="field_albuteroluse" value="not used the rescue medication at all|used rescue medication"][checkbox name="field_albuterolfrequency" value="~ once a week or less|~ 2 to 3 times a week|~ 1 to 2 times a day|~ more than 3 times a day"].

Exercise-induced symptoms:
Patient's symptoms [checkbox name="field_interfereactivity" value="do not interfere with exercise or activity|interfere with exercise or activity only when ill|sometimes interfere with exercise or activity, even when well|always interfere with exercise or activity"].
[text]

Recent exacerbations:
There have been [text] hospitalizations, [text] ICU admissions, [text] ER/Urgent Care visits, [text] outpatient visits, and [text] systemic steroid burst/s since last visit to Peds Pulmonology office.
[text]

[checkbox name="field_recentexacerbation" value="No exacerbations since last visit|Most recent exacerbation was"][text].

[checkbox name="field_symptomspresent" value="Usual symptoms include"] [checkbox name="field_symptoms" value="cough|wheezing|shortness of breath|chest tightness|chest congestion|nighttime awakening|no symptoms related to asthma"].
[checkbox name="field_patternpresent" value="Symptom pattern seems"] [checkbox name="field_pattern" value="year-round|seasonal|episodic|non-specific/random"][text].
[checkbox name="field_triggerspresent" value="No clear trigger/s|Trigger/s include"] [checkbox name="field_triggers" value="dust|URI|mold|dustmites|cockroach|animal dander|pollen|smoke|changes in weather|activity (e.g., playing, exercise)"][text].

[text]
Date of last visit:

Current Management: Patient is on -


Spacer Use for Metered Dose Inhalers:


Spacer Technique:


Medication Adherence:
Average frequency of missed doses of controller medication is about .


Allergy Medications:
Nasal Spray:
Oral Antihistamines:

Recent Asthma Control (past 4 weeks):
Patient has had .
Nocturnal symptoms .
Patient has .

Exercise-induced symptoms:
Patient's symptoms .


Recent exacerbations:
There have been hospitalizations, ICU admissions, ER/Urgent Care visits, outpatient visits, and systemic steroid burst/s since last visit to Peds Pulmonology office.


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Result - Copy and paste this output: