Asthma Sympton Tracker Patient’s name_________________________________________
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Place an X in the box for the day of the month that you experience any symptoms listed on the left-hand side of the page. Please mark boxes for days asthma medication is given. 1
Asthma Symptoms: Wheeze Cough Shortness of Breath Coughing at Night or Awakening with difficulty breathing Exercise Symptoms Allergy Symptoms: Nasal Congestion Nasal Drainage Watery, Red, or Swollen Eyes Reflux Symptoms Burping Vomiting Heartburn Best Peak Flow Reading Morning Evening
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Medications Taken Today Quick Relief (Albuterol, Maxair) Controller Oral Steroid (Orapred, Prednisone)
Place an X in the box for the day of the week you have any symptoms listed on the left-hand side of the page. Please mark boxes for days asthma medication is given. Sun Mon Tues Wed Thurs Fri Sat
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Asthma Symptoms: Wheeze Cough Shortness of Breath Coughing at Night or Awakening with difficulty breathing Exercise Symptoms Allergy Symptoms: Nasal Congestion Nasal Drainage Watery, Red, or Swollen Eyes
13123 E. 16th Avenue, Aurora, Colorado 80045 • 720-777-1234 • Toll-free: 800-624-6553
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“In Care of Kids” is a trademark of The Children’s Hospital. It is used on patient and family healthcare educational materials produced by the Hospital. This information has been reviewed and approved by designated staff of The Children’s Hospital. It is intended to supplement, not replace, medical information provided by the healthcare provider.
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Reflux Symptoms Burping Vomiting Heartburn Best Peak Flow Reading Morning Evening Medications Taken Today Quick Relief (Albuterol, Maxair) Controller Oral Steroid (Orapred, Prednisone)
Julia Micalizzi RN MSN AE-C July 2007
Approved by the Patient Family Education Committee
© 2007 The Children’s Hospital, Aurora, Colorado
13123 E. 16th Avenue, Aurora, Colorado 80045 • 720-777-1234 • Toll-free: 800-624-6553
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“In Care of Kids” is a trademark of The Children’s Hospital. It is used on patient and family healthcare educational materials produced by the Hospital. This information has been reviewed and approved by designated staff of The Children’s Hospital. It is intended to supplement, not replace, medical information provided by the healthcare provider.