Patients:FREE!

FREE – That catches everyone’s eye!!!

Below is an intake questionnaire for you to fill out regarding you or your family member’s asthma. Fill out the material and email back in to us- AsthmaCPG@gmail.com. We will review and give comments on how you/your family member’s asthma is controlled. We recommend you take/email the intake to your provider for consideration in your current care.

Include an Asthma Control Test (ACT) questionnaire (links below) would really help us and your provider!

Adult ACT questionnaire: http://www.asthma.com/resources/asthma-control-test.html

Child ACT questionnaire: http://www.asthma.com/resources/childhood-asthma-control-test.html (don’t forget to have the child answer the kid’s portion- with faces).

Intake questionnaire BLANK

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s