When evaluating asthma patients, especially children, it is very important to ask as many questions as possible to get a full picture of the environments in which they spend significant amounts of time. This asthma intake form will help determine what environmental asthma triggers may be present and how the patient can avoid exposure.
NEEF’s Environmental History for Pediatric Asthma Patient form is intended for use with children diagnosed with asthma. Designed for ease of use, the intake form is intended as an initial tool. This form should also be used to elicit information on triggers commonly overlooked.
This form is available in the following languages (click to download):
Interested in more Pediatric Asthma Resources?
Visit our Pediatric Asthma Page.