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
Berkshire School – Student Health Service Medication Letter Dear Parents, Students and Guardians, Berkshire School’s medication policy has been developed to insure the health and safety of all students. Please read and review this policy thoroughly with your child before beginning school. The Commonwealth of Massachusetts requires that we have a written order for each prescription
PRINT CONCEPT srl str. Oleg Danovski 42, bl. BM3, parter 900525 Constanta telefon/fax: 0241.550741 [email protected] Preturile sunt exprimate in EURO, nu includ TVA, si pot fi modificate fara notificare prealabila. PRINT CONCEPT srl str. Oleg Danovski 42, bl. BM3, parter 900525 Constanta telefon/fax: 0241.550741 [email protected] Curved tin with approximately 40 sugar free min
Paediatric Asthma Intake Form