Name:
Last Name
First Name
DOB:
Gender: M
F
Asthma/ Breathing Questionnaire
Middle Name
CIF:
(AQ)
Please complete both sides of this form and return to the Health Office. (The following information will be shared with necessary school personnel. It will help us take care of your child at school.) Person to Contact:
School Year:
Relationship:
Phone (Work/Home/Cell):
1. 2. Health Care Provider:
Clinic:
Private
Phone (Work/Home/Cell):
(
)
(
)
(
)
(
)
Phone: (
Health Insurance:
Date Completed:
Medical Assistance
)
1. Child’s age at diagnosis of asthma:
MN Care
No Insurance
.
2. Last school year, how many days of school did your child miss due to his/her asthma/breathing problems? 0 days 1–2 days 3-5 days 6-9 days 10-14 days
15 or more days
3. In the past 12 months, has your child been hospitalized overnight or longer for asthma/breathing problems? No Yes If yes, number of times 4. In the past 12 months, has your child been treated in the Emergency Department for asthma/breathing problems? No Yes If yes, number of times 5. In the last 4 weeks, during the day, how often has your child had asthma symptoms (wheezing, coughing, shortness of breath, chest tightness, or pain)? 0 days 1-2 days/week 3-6 days/week Everyday Throughout the day a
a
b
c
c
6. In the last 4 weeks, during the night, how often has your child had asthma symptoms tightness, or pain)? 0-1 night/month 2–3 nights/month 2 or more nights/week a
b
(wheezing, coughing, shortness of breath, chest
c
7. In the last 4 weeks, how much of a problem has your child’s asthma/breathing been during exercise, sports, playing hard, or other activities? Not a problem A little problem A big problem Hardly able to do anything a
b
b
c
8. In the last 4 weeks, how often has your child used their rescue medication episode or breathing problem? 0 days 1-2 days/week 3-7 days/week a
a
b
9. In the past 12 months, how many times has your child taken oral steroids an asthma episode or breathing problem? Never Once 2 times or more a
a
10. Does anyone in the household smoke?
(Albuterol, Xopenx inhaler, or nebulizer)
c
for an asthma
Several times per day
(Prelone, Orapred, Prednisone, Pediapred, or Prednisolone)
for
b-c
No
Yes
11. What triggers your child’s asthma/breathing problem or makes it worse? Smoke Grass/flowers/pollen Having a cold/respiratory illness Animals/pets Mold Stress or emotional upsets Dust/dustmites Changes in weather/very cold or hot air Cockroaches Strong smells/perfumes/lotions Exercise, sports, or playing hard Strong smells/cleaning products
Foods (which ones):
Complete reverse side
A-5
Rev. 5/17/12
12. What are your child’s usual signs/symptoms of an asthma episode or breathing problem? Wheezing Shortness of breath Difficulty breathing Itchy throat Coughing Irritable/crabby Chest tightness Waking up at night Stomachache
Other:
13. Does your child have a written Asthma Action Plan (AAP)?
No
Yes
Don’t know
14. Does your child use a peak flow meter (something he/she blows into to check his/her lungs)? No Yes Don’t know 15. Does your child usually use a spacer or holding chamber with his/her inhaler? Yes No Don’t know Don’t have an inhaler 16. Please list the medications your child takes for asthma or allergies (everyday medications and medications taken when needed). ASTHMA MEDICATIONS TAKEN AT HOME: Medication Name?
How Much?
When is it Taken?
ASTHMA MEDICATIONS TO BE TAKEN AT SCHOOL: Medication Name?
How Much?
When is it Taken?
17. Please list anything else you use for your child’s asthma/breathing problem (tea, herbs, home remedies, etc). 18. Please add anything else that you would like the Health Office to know about your child’s asthma/breathing problem. Authorization: • The purpose of this form is to facilitate communication between the health care provider and the Health Office as it relates to your child’s asthma so as to meet your child’s need in the school setting and to ask for your consent, or authorization, to request information from your health care provider and to release information to your health care provider from Saint Paul Public Schools (SPPS) professional staff. • I agree that my child’s care provider may release information to the SPPS professional staff, and/or request information from SPPS professional staff as it relates to my child’s asthma. • I agree that SPPS professional staff may release information to the health care provider and/or request information from the health care provider as it relates to my child’s asthma. • Legally, you may refuse to sign. Services are not conditioned upon this release of information. • I understand that the consent takes effect the day that I sign it and expires one year from the date of my signature. • I understand that I may revoke this consent at any time by giving written notification. • It is the practice of SPPS not to redisclose records without consent. • A photocopy/fax of this consent, which has not been altered, will be treated in the same manner as the original. • You may ask for a copy of the records disclosed. Parent/Guardian Signature
Date
For Office Use Only: Level of Risk/Impairment Assessment A-5
Well controlled
Not well controlled
Date:
Very poorly controlled Rev. 5/17/12
