FLORIDA DEPARTMENT OF JUVENILE JUSTICE
Treatment Flow Sheet: Asthma
NAME OF YOUTH: ______________________________ DJJID #: ______________________________
FACILITY NAME: _______________________________ ALLERGIES:____________________________
Who made the diagnosis? ______________________________________________________________________
When and where was it diagnosed? ______________________________________________________________
If diagnosed prior to commitment, who most recently treated the condition? _______________________________
When? ______________Where? _________________________________________________________
What treatment was ordered? ____________________________________________________________
When was treatment last received? ________________________________________________________
When were symptoms last experienced? ____________________________________________________
Prior treatment confirmed by: Old records in chart Report from facility or MD’s office
Parent/guardian Youth’s account
Age of onset: _________ Type: Intrinsic Extrinsic Infectious Other _____________
Triggers: _____________________________________
Visit date
Next appt
Education
documented?
Diet restrictions?
Other restrictions?
Special needs?
Alert log listing?
Height Weight
Temperature
Pulse Respiration
BP
Peak flow
Pulse ox. O2 sat
Rales?
Wheezes?
Dyspnea?
PRN inhaler use:
>1/day, >1/wk, >1/mo,
< 1/mo, none
Exacerbation visits?
Observation stays?
Hospitalizations?
Bronchodilator inh. Rx?
Steroid inh. Rx?
Antibiotic Rx?
P.O. steroid Rx?
P.O. bronchodilator Rx?
Other Rx?
FORM HS 034
PAGE 1 OF 1
Rev. 10/06