ASTHMA HISTORY FORM
Student’s Name: Date of Birth:
History Taken by: Date:
Parent/Guardian Name:
Home Phone: ( ) Work Phone: ( )
Alternate Contact: Phone: ( )
Primary Health Care Provider: Phone: ( )
Address:
When was this student’s asthma first diagnosed?
How many times has this student been seen in the emergency room for asthma in the past year?
How many times has this student been hospitalized for asthma in the past year?
Has this student ever been admitted to an intensive care unit for asthma?
When?
How would you rate the severity of this student's asthma?
(not severe) 1 2 3 4 5 6 7 8 9 10 (severe)
How many days would you estimate this student missed last year because of asthma?
What triggers this student's asthma?
❏ exercise ❏ respiratory infection ❏ strong odors or fumes ❏ stress
❏ cigarette smoke ❏ wood smoke ❏ pollen
❏ animals (specify):
❏ foods (specify):
❏ carpets ❏ indoor dust ❏ outdoor dust
❏ chalk dust ❏ temperature changes ❏ molds
❏ other:
What does this student do at home to relieve asthma symptoms (check all that apply)?
❏ breathing exercises ❏ rest/relaxation ❏ drinks liquids
❏ takes medications (see below) ❏ uses herbal remedies (see below)
❏ other (please describe):
AMES: Asthma Management in Educational Settings American Lung Association of Washington-02/01 1
