Pediatrician and young patient with parent

Asthma Environmental History Form

NEEF’s Environmental History for Pediatric Asthma Patient in English and Spanish is intended for use with children already diagnosed with asthma. Designed for ease of use, the form is intended as an initial intake tool. It is very important to ask about all environments in which a child with asthma may be spending significant amounts of time. This form should also be used to elicit information on triggers commonly overlooked.