Patient Self-Assessment Sheet for Follow-Up Visits 2012
Name:________________________________________
Date:____________________________
Your Asthma Control
How many days in the past month have you
had chest tightness, cough, shortness of breath,
or wheezing (whistling in your chest)?
____0-5
____6-10
____11-15
____16-20
____21-25
____26-30
How many nights in the past month have you
had chest tightness, cough, shortness of breath,
or wheezing (whistling in your chest)?
____0-5
____6-10
____11-15
____16-20
____21-25
____26-30
Do you perform peak flow readings at home?
____yes
____no
If yes, did you bring your peak flow chart?
____yes
____no
How many days in the past month has
asthma restricted your physical activity
or caused missed days from school/work?
____0-5
____16-20
____21-25
____26-30
Have you had any asthma attacks since
your last visit?
____yes
____no
Have you had any unscheduled visits to a
doctor, including to the emergency
department or urgent care clinic, since
your last visit?
____yes
____no
How well controlled is your asthma,
in your opinion?
____very well controlled
____somewhat controlled
____not well controlled
____6-10
____11-15
How many times per week do you use your rescue inhaler? __________________________________________________
Do you use your rescue inhaler at night?
__________________________________________________
Taking Your Medicine
What problems have you had taking your medicine or following your asthma action plan?
Please ask the doctor or nurse to review how you take your medicine.
Your Questions
What questions or concerns would you like to discuss with your doctor?
How satisfied are you with your asthma care?
____very satisfied
____somewhat satisfied
____not satisfied