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Queen’s Family Health Team
Provider Asthma Assessment Form (PAAF)
Asthma Diagnosis N/A

Pulmonary Function Measurement Children (6 years+) Adults
PREFERRED: Spirometry showing reversible airway obstruction
Reduced FEV₁/FVC
AND
Increased FEV₁ after a bronchodilator or after course of controller therapy 		Less than lower limit of normal*
(<0.8-0.9)**
AND
≥ 12% 		Less than lower limit of normal*
(<0.75-0.8)**
AND
≥ 12%
(and a minimum > 200 mL)
ALTERNATIVE: Peak expiratory flow (PEF) variability
Increase after a bronchodilator or after a course of controller therapy
OR
Diurnal variation 		≥ 20%
OR
Not recommended 		60 L/min
(minimum ≥ 20%)
OR
>8% based upon twice daily readings;
>20% based upon multiple daily readings
ALTERNATIVE: Positive challenge test
a) Methacholine Challenge
OR
b) Exercise Challenge 		PC₂₀ <4mg/mL
(4-16 mg/mL is borderline; 16 mg/mL is negative)
OR
≥10-15% decrease in FEV₁ post-exercise
Recurrent asthma-like symptoms or exacerbation
AND
Documentation of airflow obstruction Preferred
Documented wheezing or other signs of airflow obstruction observed by a heath care provider
Alternative
Convincing parental report of wheezing or other symptoms
AND
Documentation of reversibility of airflow obstruction Preferred
Response to bronchodilator within 30 min confirmed by a health care provider
Alternative
Gradual but clear response to anti-inflammatory therapy: after ≥ 4 hours of oral corticosteroid (OCS), within 3 months of moderate dose inhaled corticosteroid (ICS), expect decreased symptoms and exacerbation frequency and severity.
Alternative
Response to bronchodilator within 30 min by parental history
AND
No clinical evidence of an alternative diagnosis

Family History of Lung Disease N/A
Parent Sibling Unknown
Allergy - Drug
Allergy - Environmental
Allergy - Food
Allergy - Furry Pets
Asthma
Atopic Dermatitis
COPD
Smoking N/A


Asthma Severity N/A
      
Yes No Unknown Recent (≤ 1 year)
Respirologist
General Internist
Allergist
Pediatrician
Yes No Unknown Recent (≤ 1 year) Total # ever
Asthma exacerbation ever
ED visits ever for asthma
Hospitalized ever for asthma
Near fatal asthma episode


Occupational History N/A
  
  
Medications N/A

LABA LAMA LABA/LAMA LTRA Biologics Other
Yes No Unknown
Is patient using inhaled corticosteroids (ICS)?
Beta-Blockers
NSAIDS
Patient has a spacing device
Does at least one prescribed medication allow for a spacing device to be used?
Adherence issues known or suspected
Unfilled prescriptions
(In the last 6 months has the patient been prescribed any asthma medication he/she has not obtained.)
Asthma Control N/A
   
{{ asthmaControlled }}
Care and Management / Referrals N/A
Yes No
Device Technique Assessed
Device Technique Corrected
Triggers addressed
Environmental controls reviewed
Barriers addressed
Referred to an asthma education program/CRE
Expected Severe Asthma
Referred to Asthma Specialist for Suspected Severe Asthma
Asthma Action Plan N/A
Yes No
Written asthma action plan provided
Written asthma action plan revised
Asthma action plan reviewed & not changed
Yellow or red zone of action plan followed since last visit
Asthma Control Zone N/A
Pulmonary Function Test N/A
Assessment Tools N/A
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