Insert your Health Centers Name Here
Asthma Flow Sheet
Notes
/Vital Signs and Lung Function Tests
Height: ______Weight: ______Resp.Rate: ______Pulse: ______Temp: ______
BP: _____/_____ Pulse Ox: ______%
Spirometry/FEV1: ______% Post-tx: ______%
Unable to perform
Peak Flow: Pers. Best ______Est. for Ht ______
Peak Flow Rate: ______# ______%
Post-txPeak Flow Rate: ______# ______%
Is the patient having an exacerbation? ___ yes ___ no
Has the pt had a recent trigger exposure? ___ yes ___ no
Current Symptoms
/Recent Daytime Sx’s
/Recent Nighttime Sx’s
/B2-Agonist Use
___ No Symptoms___ Wheeze
___ Cough ___ Sputum
___ Chest tight/dyspnea
___ SOB
Other: / ___ 0 days/week
___ 1-2 days/week
___ 3-6 days/week
___ Every day
___ Continual
(multiple symptoms/day) / ___ 0 x/month
___ 1-2 x/month
___ 3-4 x/month
___ 5-11 x/month(1-2 x/wk)
___ 12 x/month (>3/wk) / ___ None
___ 1-2 days/week
___ 3-6 days/week
___ 7 days/week
___ > 2x every day
___ Avg. # puffs/day
ER Visits
/Missed School
/HomePeak Flow Rates
/Triggers
(in the last month)___ 0 ___ 1 ___ 2
___ 3 ___ 4 ___ >4
Hospitalizations in last year: ______/ (d/t asthma, last 2 weeks)
___ None ___ 5-6 days
___ 1-2 days ___ 7-8 days
___ 3-4 days ___ 9-10days / Range: ______
___ Green Zone
___ Yellow Zone
___ Red Zone
___ No PFM / ___ No known
___ Cigarette smoke ___ Exercise
___ URI
___ Dust ___ Carpet
___ Mold
___ Pollen
___ Cat ___ Dog
___ Cockroaches
___ Season: ______
___ Other: ______Co-Morbidities /
Impact on Activity
/ Environmental___ Allergic Rhinitis
___ Allergic Conjunctivitis___ Eczema ___ Sinusitis
___ Obesity ___ GERD
___ Other: ______/ __ No effect on any activity
__ May affect phys. activity
__ Activity often affected
__ Limited physical activity
Describe:______/ Problems/Concerns:______
______
Physical Exam
/Current Medications
Chest/Respiratory: ___ Lungs clear to auscultation___ Shallow breath sounds: ______
___ Wheeze: Describe ______
___ Retractions: Describe ______
___ Prolonged Expiration ___ Nasal Flaring
___ Other sounds: Describe ______
EENT: ______
Skin: ______
Other signs:______
______/ ______
______
Pt has spacer? ___ yes ___ no. Uses? ___ yes ___no
Med Adherence: ___ Poor ___ Fair ___ Adequate
Treatment at Visit
Xopenex/levalbuterol neb:__ 0.63mg __ 1.25mg/3ml
Albuterol neb: ___ 2.5 mg/3ml ___ Other: ______
___ # of treatments ___ Prelone given; dose:_________ Pt. Referred to ER: ___ Yale ___ St. Raphael’s
___ Flu shot ___ Other: ______
Other diagnosis:PRINT Provider Name:
/Other treatment plan:
Follow-Up
/Referrals
___ 2 weeks ___ 4 weeks ___ 2 months
___ 3 months ___ 6 months ___ other: /___ Allergist ___ Pulmonologist (Yale/St.Raph’s)
___ Visiting Nurse ___ Other: ______Asthma Action Plan: ___Given ___ Pt already has
/ ___ Dust mite covers ordered ___ Pt already hasContinued on Back (Severity Assessment, Treatment Plan, and Teaching)
Name: / HHC #:Drug Allergies: / DOB:
Today’s Date: / Study Visit #:
Page Two, Asthma Flow Sheet
UNDERLYING SEVERITY RATING(asthma untreated, uncontrolled, worst season)
Mild Intermittent Mild Persistent Moderate Persistent Severe Persistent
TODAY’s CONTROL RATINg (use corresponding rating for highest mark in any column)
Daytime cough, wheeze, SOB, or chest tightness / Nighttime cough, wheeze, SOB, or
chest tightness / B2-Agonist Use /
Impact on activity
/FEV/PEF
/ Control RatingContinual / 12 nts/month / >2x every day / Limited physical activity / 60% /
Very Poor
Every day / 5-11 nts/month / 7 days/wk / Activity often affected / >60<80% /Poor
3-6 days/week / 3-4 nights/month / 3-6 days/wk / May affect physical activity / 80% /Fair
1-2 days/week / 1-2 nights/month / 1-2 days/wk / None / 80% /Good
None / None / None / None / 80% /Excellent
TODAy’s visit MedicationS (based on Today’s Control)CONTROLLERS / / DOSE / FREQ /
CONTROLLERS
/ / DOSE / FREQ / QUICK-RELIEF / / DOSE / FREQInhaled Corticosteroids / Mast Cell Stabilizers / Short-acting
Beta-agonist
Fluticasone / Cromolyn neb. soln.
20 mg/amp / Albuterol MDI 90 mcg
FloventMDI 44 mcg / Proventil MDI 90 mcg
Flovent MDI 110 mcg / IntalMDI 800 mcg / Ventolin MDI 90 mcg
Flovent MDI 220 mcg / Albuterol neb soln. 2.5 mg/3ml prediluted
FloventDPI 50 mcg
/ Anti-LeukotrienesFlovent DPI 100 mcg
/ Montelukast /Albuterol 0.5% soln. Dilute for neb with:
FloventDPI 250 mcg / Singulair 4 mg chew.Budesonide
/ Singulair 5 mg chew. / LevalbuterolPulmicort Respules
0.25 mg/2ml / Singulair 10 mg tab / Xopenex 0.63mg/3ml neb. soln.
Pulmicort Respules
0.50 mg/2ml
/ Long-acting Bronchodilators /Xopenex1.25mg/3ml neb. soln.
PulmicortTurbuhaler 200 mcg
/ SalmeterolSerevent MDI 21mcg / Oral Steroids
Beclomethasone / Serevent DPI 50 mcg /
Prednisone
Vanceril 42 mcg / 5 mgBeclovent42 mcg / Combination Drugs /
10 mg
QVAR MDI 40 mcg
/ Advair DiskusFluti-casone + Salmeterol / 20 mgQVAR MDI 80 mcg /
Prednisolone
Triamcinolone / 100mcg Flut/50 Sal /Pediapred 5 mg/5ml
Azmacort100 mcg / 250mcg Flut/50 Sal /Prelone 15 mg/5ml
500mcg Flut/50 Sal /Orapred 15 mg/5 ml
Spacer (write-in)Provider Signature: ______
Asthma Education
Teaching provided by: ______, ______(Title)Inhaler/spacer technique: __ Explanation __ Demo __ Pt Re-demo __ Sample Technique? __ satisfactory __ unsatis.
Peak Flow Meter: ___ Explanation ___ Demo ___ Pt Re-demo ___ Sample
___ Explanation of asthma ___ Action Plan/Self Management ___Trigger avoidance ___ Environmental control
Referral to Asthma Education Group: ______Patient Goal: ______
Notes: ______
Patient Name
/D.O.B.
/HHC#
/DATE