Paediatric_asthma_intake_form _2_

Paediatric Asthma Intake Form
An accurate health history is important to ensure that it is safe for you to receive treatment. If your health status changes in the future, please let us know. All information gathered for treatments is confidential except as required or allowed by law to facilitate diagnosis (assessment) or treatment. You will be asked to provide written authorization for release of any information. Today’s Date:_________________________ Birthdate:______________________ Name:______________________________ Parents Name(s):___________________ Address:________________________________________________________________ Phone Number:_________________________ Email Address ___________________ Physician:_____________________________ Tel:____________________________ Are you under the care of a physician now? ___Y ___N
If yes, for what? ______________________________________________

Referred by:_____________________________
In Emergency Notify:______________________ Relationship:___________________

Asthma History

How long have you had asthma?_____________________________________________
When and how was your asthma diagnosed?
________________________________________________________________________
________________________________________________________________________
What seemed to be the initial cause of your asthma?
_______________________________________________________________________

_______________________________________________________________________

Asthma Symptoms (please check any of the following symptoms you currently have, or
have had in the past)
 wheezing
 sneezing  chest tightness low immunity How many days per week/month do you have symptoms during the day? ________________________________________________________________________ How many days per week/month do you have symptoms during the night? ________________________________________________________________________ How often do you suffer from an acute attack or exacerbation of your symptoms? ________________________________________________________________________ Have you ever been hospitalized or needed emergency care for your asthma? If so, how often?___________________________________________________________________ Is it getting worse? ____Y ____N Does it affect your ____sleep ____work/play ____other (please specify)
What makes it better?______________________________________________________
How frequently are you absent from work/school due to your asthma?
_______________________________________________________________________
Asthma Triggers (please check any of the following asthma triggers that currently {or
have had in the past} aggravate your asthma:
 dust
 pol ution  food  food additives Other CurrentTreatments___________________________________________________

Family Medical History

Allergic Rhinitis? ____Y ____N
Other(please specify)___________________________________________________ Have you been immunized for the following(please check all that apply)  diphtheria
Please indicate if there was any side effect from any of the above immunizations
________________________________________________________________________
________________________________________________________________________
Past Medical History (please check any of the following conditions you currently have,
or have had in the past)
 jaundice
 born premature  impetigo  bedwetting ________________________
Surgeries(list)
________________________________________________________________________
Major Trauma (car accident, fall, etc.)
________________________________________________________________________

Asthma Medication
Are you currently taking any of the following asthma medications (please include
frequency, form of administration and dosage)?
Bronchodilators (quick acting/rescue medication)
-Please check your current medication:
 Airet ®

·dosage/frequency ____________________
Inhaled Steroids
-Please check your current medication:
 Beclovent ®

· dosage/frequency ____________________
Long-acting beta-agonists
-Please check your current medication:
 Serevent ® (salmeterol)
Is your child currently on any prescribed medicine? _____Y _____N Is your child currently taking any non-prescribed medicine (for i.e. herbs, vitamins, supplements, etc.)? ____Y ____N Has your child taken antibiotics before? _____Y _____N If yes, number of times: ___________________________ Excluding the above listed medicine, has your child taken any other medicine in the past? _________________________________________________________________________ Diet (please complete the sample menu according to an average day)
Morning___________________________________________________________________
Noon______________________________________________________________________ Evening____________________________________________________________________Snacks (when & what)________________________________________________________ Does your child eat or drink the following (if so how often)?  Juice Was your child breast fed? ____Y ____N When and how did you introduce solid food? ________________________________________________________________________________________________________________________________________________ Signature____________________________________ Thank you for taking the time to fill out this form. All information is confidential and will not be released for legal or medical purposes without your consent. 110-171 East Liberty St. Toronto M6K 3P6 Tel. 416-588-8282 Fax 416-588-2643

Source: http://www.balanceih.com/balance_paediatric_asthma.pdf