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BayCare Medical Group

20 S. Santa Cruz Avenue, Ste. 300

Los Gatos, CA 95030

408-402-2452

Pediatric Asthma & Chronic Cough Visit History

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Child's Name

PARENT OR CAREGIVER: Please complete questions 1-9

1. In the past 6 months, how many days of school or day care has your child missed because of his/her asthma?
2. 1n the past 6 months, how many times did your child need to go to the emergency room or urgent care because of his/her asthma?
3. 1n the past 6 months, how many times was your child admitted to the hospital because of asthma or asthma complications?
4. 1n the past month during the DAY, how often d1d your child's asthma cause any of the follow1ng: coughing spells, shortness of breath, wheezing, or reduced activity?
S. In the past month at NIGHT, how often did your child's asthma cause any of the following: coughing spells, shortness of breath, wheezing, or waking up?
6. In the past month, how well was your child's asthma controlled?
7. I would like to know more about
8. On a scale of 1-10, how confident are you in managing your child's asthma?

PHYSICIAN: Completes questions 10-18

11. What is the patient's asthma severity level?
12. What controller medication(s) is the patient prescribed by you or another provider?
13. In the past month, how well was the patient's asthma

Signed: Richard B. Fox, M.D., J.D.