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Pediatric Asthma Initiative: Environmental History Form

This form is intended for use with children already diagnosed with asthma. Designed for ease of use, the Environmental History Form is obviously not comprehensive and is intended as an initial intake tool.

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It is very important to ask about all environments in which a child with asthma may be spending significant amounts of time, including all residences where the child sleeps or spends time: schools, daycares, camps, work, recreational activities, and college dorms (for 17-18 year olds). This form should also be used to elicit information on triggers commonly overlooked, such as weekly trips to a relative where a hobby or pet is located. Practitioners should use a great deal of sensitivity in taking in an environmental history. Some families are aware of possible connections between behavior, conditions in the home and school, and pediatric asthma. Others are unaware of the linkages, and the environmental history will be the first opportunity to make these connections.