Asthma Care Map For Primary Care N/A Demographics N/A Client Name

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Client Name (please print) Initial Assessment Date YYYY/MM/DD Visit Scheduled Client Identifier Type Unscheduled Referring health care provider Healthcare Professional Role Type Provider identifier assigning authority Provider Identifier Type e.g Regulatory body for physicians & surgeons e.g provider billing number Reason for referral Asthma and COPD overlap e.g respirologist New Asthma Diagnosis Yes Suspected Asthma e.g OHIP Date of Birth YYYY/MM/DD Postal / Zip Code Self Reported Ethnic Group No Height N/A Weight Male gender Gender diverse High school High school Post secondary Bachelor’s degree Bachelor’s degree Post secondary Bachelor’s degree Highest level of education Suboptimal Asthma Control Other Sex Assigned at Birth Female gender BMI cm Client Identifier Assigning Authority e.g Jurisdictional Health Number Lived Gender Anthropometric Vitals Severe Asthma N/A N/A Demographics Asthma Care Map for Primary Care Living With kg Caregiver Partner Lives alone Other N/A Asthma Diagnosis Unknown Confirmed Suspected Excluded YYYY/MM/DD # Date Confirmed/Excluded Age asthma was confirmed Method used to confirm Asthma Diagnosis Method used to confirm Asthma Diagnosis (for individuals 6 years and older and younger individuals able to do spirometry) Pulmonary Function Measurement (for individuals 1-5 years of age NOT able to do spirometry) Adult Children (6 years and older) Recurrent Asthma Like Symptoms of Excerbation PREFERRED: Spirometry showing reversible airway obstruction Reduced FEV1/FVC AND Increased in FEV1 after a bronchodilator or after course of controller therapy Spirometry or PEF attached (If uncertain indicate “unknown” in the provided field) Less than lower limit of normal* ( 0.75-0.8)** Less than lower limit of normal* ( 0.8-0.9)** AND AND 12% (and a minimum 200ml) 12% Preferred Documented wheezing or other signs of airflow observed by a health care provider Documentation AND of airflow obstruction Alternative Convincing parental report of wheezing or other symptoms ALTERNATIVE: Peak Expiratory Flow (PEF) variabilty Increase after a bronchodilator or after course of controller therapy OR Diurnal variation Not recommended Preferred Response to bronchodilator within 30min confirmed by a health care provider 60 L/min (minimum 20%) 20% OR OR 8% based upon twice daily readings; 20% based upon multiple daily readings ALTERNATIVE: Positive Challenge Test a) Methacholine Challange OR b) Exercise Challenge-----* Based on age, sex, height and ethnicity. Documentation AND of reversibility of airflow obstruction Alternative 1 Gradual but clear response to an anti-inflammatory therapy: after 4 hours of oral cortical steroids (OCS), within 3 months of moderate dose inhaled cortical steroids (ICS), expect decreased symptoms and exacerbation frequency and severity. Alternative 2 Response to bronchodilator within 30 min by parental history PC20 4 mg/mL (4-16 mg/mL is borderline; 16 mg/mL is negative) OR AND No clinical evidence of an alternative diagnosis 10-15% decrease in FEV1 post-exercise ** Approximate lower limits of normal ratios for children and adults. This information was orginally published in CAN Respir J2012;19(2);127-164 This information was orginally published in CAN Resp J2015;22(3);135-143 N/A Medications Respiratory Medications Drug Name Strength Unit of Measure Dose Route Rx Date Adherence issues known or suspected? Y/N Reliever Yes No Patient has a spacing device Does at least one prescribed medication allow for a spacing device to be used? Inhaled Corticosteriod (ICS) ICS/LABA combination Long Acting Beta-Agonists (LABA)* Unfilled prescriptions. In the last 6 months has the patient been prescribed any asthma medications he/she has not obtained. Leukotriene receptor antagonist (LTRA) Reliever/Controller Past Medications Prednisone Biologics Nicotine product Medications prescribed at this visit Yellow Zone Medications Long acting muscarinic antagonists (LAMA) Other * Should not be used as a standalone Lung Health Information Line 1-888-344-LUNG (5864) September 15, 2020 Version 2 Page 1

Client Name Jurisdictional Health Number N/A Family History of Lung Disease Family History of Asthma, Allergy and/or COPD Yes No Risk Factors Unknown (If yes select allergic conditions from a list and indicate which relative) Unknown History of Previous Severe Exacerbation (requiring either systemic steroids, ED visit or hospitalization Yes No Unknown Unknown Poorly controlled asthma as per CTS criteria Yes No Unknown Unknown Current smoker Yes No Unknown Both None Unknown Allergy Parent Sibling Both None Unknown Allergy drug Parent Sibling Both None Unknown Allergy food Parent Sibling Both None Unknown Eczema Parent Sibling Both None Environmental allergies Parent Sibling Both None N/A Smoking Quit Date Pack Years 1-6 months Cig Smoked/day Years smoked x 20 Yes Cannabis use Advise Use of other tobacco Sputum Frequent colds Other inhaled substances If yes frequency maintenance Arrange 4-7/year within 6 months beyond 6 months not planning to quit N/A Visit(s) to family physician in the last 12 months for asthma symptoms Symptoms worse at night(including cough) Chest pain N/A Barriers Barriers Yes No (If yes select from the list below) Yes Urgent primary care visits Cultural issue Effect of substances abuse Visit(s) to a specialist for asthma Yes No Unknown Respirologist Last 12 Months Financial issue Lack of private drug plan General Internist Language Allergist Literacy Pediatrician Medication side effects Yes No Unknown Recent 1yr Total # ever Other Hospitalized ever for asthma N/A Breath Sounds Near fatal asthma episode (coma/intubated/icu/CO2) Normal # Abnormal If abnormal, select auscultory finding # ICU admissions # intubations ICU admissions in the last 12 months Wheezes Crackles Reduced Bronchial (harsh and prolonged inspiration and expiration) Date last used Systemic steroid use ever Pregnancy Social/Family issues ED visits ever for asthma Recent best FEV1 or PEF 60% predicted No Adherence If Yes, indicate the number of primary care visits for asthma in the last 12 months Routine primary care visits 8/year Symptoms worse at morning(including cough) within a month AllergySeverity Asthma 0-3/year Colds that last longer than 7 days Are you planning to quit smoking? Smoking Cessation Addressed Ask Wheeze Smoking Cessation Quit Intentions contemplation action No Cough Stages of Change Addressed preparation N/A Chest tightness Pack years Inhalation vapor use pre-contemplation 1-2 cannisters/month Breathlessness e-cigarette/vaping No 2 cannisters/month Yes 1 month Other Passive Smoking Risk 1 cannister/month Current Symptoms When was the last time you smoked a cigarette, even a puff? 6 months SABA Overuse Current Smoker Quit Duration YYYY/MM/DD (If yes select from a list below) No Sibling Ex-Smoker No Yes Parent Non-Smoker Yes Exposure to Second-Hand Smoke Asthma Smoking Status N/A Risk Factors for Exacerbations Total # ever Additional Notes Lung Health Information Line 1-888-344-LUNG (5864) Page 2

Client Name Jurisdictional Health Number N/A Allergy History Allergic Condition Yes No Category Unknown If yes select patient reported triggers & exposures from list. If yes, select from the list of possible allergic conditions (Self/Parent report) Yes No Unknown Anaphylaxis Birds Bronchospasm Cats Conjunctivitis Chemicals Eczema Yes Yes Exposures No No Unknown Unknown Yes Yes No No Unknown Unknown Cold air Allergic Skin Prick Test Negative Positive Not done Self/Parent-report DD / MM / YYYY Dogs Dust/Dust mites Emotion/Stress If positive identify positive response to possible allergens listed Yes Cat Exercise No Feather bedding/Pillows Cockroaches Fireplace/Woodstove Dog Food allergy nut Dust/Dust mites Food allergy seafood Feathers Fungi/Mould Fumes Grasses Fungi/Mould Pollen Gas stove Ragweed Grasses Trees High humidity Occupational sensitizers Medications Other pets Outdoor pollution Other Perfume/Air fresheners N/A Occupational History Current Employment Status: Check all the apply. Note - This includes self-employment and working from home: Full-Time Part-Time Modified duties Other Triggers Cockroaches Rhinitis Date N/A Triggers and Exposures Shift work Pollen N/A Ragweed Respiratory Infections Retired Second hand smoke Off work due to respiratory health Trees Current Employment Did your Asthma symptoms start at work? Yes No Do/ did your Asthma symptoms worsen at work? Yes No Other If the response options are YES consider completing the WRASQ(L) questionnaire Complete WRASQ(L) today? Yes No N/A Environmental Controls Environmental Control Measures in Place Yes Yes Air conditioning in summer (If Yes, Select patient-reported, control measures in place. Optional: repeat questions for individuals with No a secondary home.) No Yes No Suggested Suggested Humidifier in winter (desired target 50%) Central or hepa-filter vacuum Humidifier all year round (desired target 50%) Dehumidifier (desired target 50%) Non-feather blanket Dust mite mattress cover Pets kept out of bedrooms Dust mite pillow cover Regular furnace filter change Removed carpets Remove pets from home Heat exchanger Wash linens in hot water Heating gas/Oil Wash pets once a week Heating electric/Radiator Wear mask or respirator as needed Alternative to wood heat (fireplaces, wood stoves, furnaces) or mitigation strategies Other Lung Health Information Line 1-888-344-LUNG (5864) Page 3

Client Name Jurisdictional Health Number N/A Comorbidities Comorbid Conditions Yes No (If yes select relevant asthma comorbid diagnosis from a list) Yes No Unknown Yes A-1 Antitrypsin deficiency Glaucoma/Cataracts Adenoid hypertrophy Immune deficiency Allergic bronchoplumonary aspergillosis Dysfunctional breathing Allergic rhinoconjunctivitis MI Anaphylaxis Osteopenia/ Osteoporosis ASA sensitivity Panic disorders Cancer Respiratory failure COPD Rhinitis/ Nasal polyposis/ Sinusitis Cor Pulmonale/ heart failure Sleep apnea Cerebrovascular accident (CVA) Swallowing dysfunction/Dysphagia No Unknown (Laryngeal Dysfunction and/or Hyperventilation Syndrome) Eczema/ Hives/ Urticaria Other cardiovascular disease Eosinophilia Eosinophilic granulomatosis with polyangiitis (EGPA) (Churg-Strauss Syndrome) Other Gastroesophageal reflux disease (GERD) N/A Asthma Control Daytime Symptoms (Average number of day/week in the last 4 weeks with dyspnea, cough, wheeze and/or chest tightness) Nighttime Symptoms (Average number of night/weeks in the last 4 weeks with dyspnea, cough, wheeze and/or chest tightness) Physical activity limited (Due to asthma in the last 4 weeks) Exacerbations since last visit (Hospital admission, ED visit, Walk-in-Clinic) Dates of Exacerbations (Hospital admission, ED visit, Walk-in-Clinic) School/Work/Social activity absences due to asthma (Average number of days/week in the last 4 weeks) Needs Reliever (Average number of day/week in the last 4 weeks) Sputum Eosinophils (Measured Yes/No: if yes, %) # of Days/Week control is 2 days/week No No Actual % Pred Actual L/Min L/Min % L/Min % FVC L/Min L/Min % L/Min % PEF L/Min L/Min % L/Min % Actual Additional Notes # of Exacerbations Predicted PEF L/Min Personal Best PEF L/Min Actual PEF L/Min PEF % pred % pred YYYY/MM/DD No # of Days/Week Actual mg/mL or mcg Asthma Action Plan N/A Yes # of Doses/Week control is 2 Yes No % Control 2-3% FEV1 or PEF 90% predicted or personal best Yes No PEF diurnal variation 15% over a 2 week period Yes No Yes No % Pred % PB Methacholine PC20 or PD20 Yes POST Actual PEF % Personal Best YYYY/MM/DD PRE FEV1 Peak Flow Meter Control 1 Yes LLN Spirometry FEV1 / FVC # of Nights/Week Yes N/A Pulmonary Function Test (Note time interval for capturing asthma control data is the last four weeks) No Written asthma action plan provided YYYY/MM/DD Written asthma action plan revised YYYY/MM/DD Asthma action plan reviewed & not changed YYYY/MM/DD Yellow or red zone of action plan followed, since last vist # of Times N/A Asthma Control Zone (Provider assessment based upon prior Asthma Control parameter responses) Asthma Controlled Based on control criteria from the 2021 CTS Guideline - a focused update on the management of very mild and mild asthma Any ONE element NOT in control- OVERALL NOT in control. If Asthma controlled option answer is Green Green If Asthma uncontrolled option is yellow or red Yellow Lung Health Information Line 1-888-344-LUNG (5864) Red Page 4

Client Name Jurisdictional Health Number N/A Immunizations Yes No Referrals N/A Unknown Yes Immunizations discussed Allergist Influenza vaccination received Asthma Education Program/ CRE Date of last influenza vaccination N/A YYYY/MM/DD Internal Medicine Specialist Results ENT physician Bone Mineral Density Test (BMD Test) YYYY/MM/DD Results g/cm² YYYY/MM/DD Results lu/ml Occupational Medication Specialist Speech Therapist IgE Date of last Smoking Cessation Program Pediatrician Chest CT Date of last Suggested Respirologist YYYY/MM/DD Investigations Date of last No Gastroenterologist Other specialist Blood Eosinophil Levels 10*3 /uL Education provided at this visit N/A Assessment Tools Education Interventions N/A Yes No (User will be asked to identify education provided at this visit by selecting items from a list) Yes No Adherence to medications Yes No Quality of Life assessment completed Mini Asthma Quality of Life questionnaire score # Barriers addressed Coping strategies addressed Follow-up Visit Scheduled in (time frame from current visit) Definition of asthma Device technique optimal Early recognition & treatment of exacerbations 1 Week 1 Month 4-6 Months Environmental tobacco smoke exposure 2 Weeks 2 Months 6-12 Months 3 Weeks 3 Months “Wait and see” Epinephrine auto injector Exercise N/A Immunotherapy Other Inhaler technique Medications Provide patient education materials Self management goal Smoking cessation Triggers & environmental controls Other Patient understanding of education/Information provided at this visit Poor Fair Good Excellent Additional Notes / Plan Lung Health Information Line 1-888-344-LUNG (5864) Page 5

Visit(s) to family physician in the last 12 months for asthma symptoms If Yes, indicate the number of primary care visits for asthma in the last 12 months Visit(s) to a specialist for asthma Yes No Unknown Last 12 Months Yes No Unknown Recent 1yr Total # ever ED visits ever for asthma Hospitalized ever for asthma ICU admissions in the last 12 .

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