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QualityTool

Pediatric Asthma Initiative: Environmental History Form


Description

This form, for health care practitioners, gathers initial information on triggers commonly overlooked with children already diagnosed with asthma. It can help physicians and families make possible connections between behavior, conditions in the home and school, and pediatric asthma. The questions on the form related to the child’s home also apply to other indoor environments where the child spends time, including school, daycare, car, school bus, work, and recreational facilities.

This tool is also available in Spanish.
Links to the Tool:
This tool is available at: http://neefusa.org/health/asthma/asthmahistoryform.htm
This tool is available in Spanish at: http://neefusa.org/pdf/AsthmaHistoryFormSP.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.)

Developer

National Environmental Education Foundation

Funding Sources

Centers for Disease Control and Prevention; Environmental Protection Agency; National Institute of Environmental Health Sciences (NIEHS)


QualityTool Topic

Disease/Condition-Related; Guideline-Related


Links to National Guideline Clearinghouse or National Quality Measures Clearinghouse:

This tool is derived from the following guideline in the National Guideline Clearinghouse (NGC): Environmental management of pediatric asthma. Guidelines for health care providers.:
http://www.guideline.gov/content.aspx?id=10019

History

  • Release Date: 08/2009
  • Original Summary: 04/2012
Disclaimer: The inclusion of a tool in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality or Westat of the tool or of the submitter or developer of the tool. Read more.
QualityTool Classification

Disease/Clinical Category:
Stage of Care:
IOM Domains of Quality:
QualityTool Format:

Last updated: May 09, 2012.