Asthma Assessment | Driscoll Health Plan

This short survey will only take a few minutes to complete and will help us monitor how you/your child(ren) are doing. All questions should be answered about the member of your family that you list below with asthma. If you would like to complete forms for more than one family member, you will be able to at the end.

* = required

Name*

First Last

Date of Birth*

I am confident that the member can take actions that will help prevent or minimize some symptoms or problems associated with the asthma.*

I am confident that I can tell when the member needs to get medical care and when I can handle a health problem myself.*

Does someone in the household smoke or vape or is the member exposed to secondhand smoke?

Yes, regularly
Occasionally
I used to smoke but I quit
Never

How often does the member have asthma attacks?*

Every day
2-3 times/week
Around once/week
2-3 times/month
Around once/month
Less than twice a year
Never

Has the member been going to doctor’s appointments?*

Yes
Most of the time
Sometimes
No

Please let us know why*

Transportation issues
Childcare issues
I forget
I cannot get off from work
I have problems making appointments
Other

You selected "Other", please describe:*

Does the member have both a controller and a rescue medication and know when to use each one?*

Yes
Somewhat
No
Not sure

Does the member take asthma medication as prescribed?*

(i.e. inhaler)

Yes
Somewhat
No
Not sure

Please let us know why.*

Please check all that apply

I can't afford the prescription
Unpleasant side effects
I forget
I ran out
I am having trouble contacting my provider
It doesn’t help
Other

You selected "Other", please describe:*

Comments

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PAM Score

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Escalate

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Escalate Comments.