My Breathing Buddy A project created by: Jodi Harris, RN, BSN, MN-NP(F) Student University of British Columbia This diary is a symptom tracker for parents of children with suspected undiagnosed Asthma. Please complete applicable areas where indicated. Bring this tool to all visits to health care providers including clinic and Emergency Department visits. Have the physician or Nurse Practitioner complete each indicated area. This tool is intended for use by practitioners in symptom mapping and trend identification only. This is not a definitive diagnostic tool. Buddy, the Diagnosis Detective Demographic Information: Parent’s Name: Telephone Number: Child’s Name: Date of Birth: If found, please return to this address: _______________________________________________ My Health History: Born at _____ weeks Weight at Birth________ Complications during pregnancy ___________________________________________________ Vaginal or caesarean birth _______________________________ Hospitalizations after birth_______________________________ Medical illnesses_______________________________________ Allergies_____________________________________________ Breast fed/formula fed/both______________________________ Other important information about my child: ______________________________________________________________________________________________________ Family Medical History: My parent’s health history (including asthma or eczema): _________________________________________ Medications used:_____________________________ They are allergic to:__________________________ My parent’s health history (including asthma or eczema): _________________________________________ Medications used:_____________________________ They are allergic to:__________________________ My sibling’s health history: _________________________________________ Medications used:_____________________________ They are allergic to:__________________________ Household Environment: Smokers in house (yes or no) _________________ Smoke in the house (yes or no) _______________ We avoid places with pets (yes or no) __________ We have a pet (yes or no) __________________ My pet is a (example: cat)__________________ At home, I had some symptoms that were scary. Date: Time: My child has been sick for _________ days My child has been sick with: (check all that apply) ___Cough ___Runny Nose ___Blocked Nose ___Fever ___Earache ___Tummy Ache/Vomiting ___Rash (itchy/not itchy) ___Not able to sleep/frequent night waking I could hear a wheeze/whistle (yes or no) ________________ I heard it worse (when breathing in or out) _______________ The symptoms were worse in the (day or night) ____________ I could see my child’s breathing change, it looked like: __ faster/heavier __neck sucking in __worried/anxious __ nostrils flaring __sitting like a tripod __other:_______ I treated my child’s symptoms with these medicines: __Inhaler blue, tan, red/pink, red (circle all that apply) __Tylenol __Antibiotics __Advil __Other: _______________ My child got better in _____ days I did/did not go to the doctor because _______________________________________________ Other information that I want you to know: ______________________________________________________________________________________________ Date: Time: My child has been sick for _________ days My child has been sick with: (check all that apply) ___Cough ___Runny Nose ___Blocked Nose ___Fever ___Earache ___Tummy Ache/Vomiting ___Rash (itchy/not itchy) ___Not able to sleep/frequent night waking I could hear a wheeze/whistle (yes or no) ________________ I heard it worse (when breathing in or out) _______________ The symptoms were worse in the (day or night) ____________ I could see my child’s breathing change, it looked like: __ faster/heavier __neck sucking in __worried/anxious __ nostrils flaring __sitting like a tripod __other:_______ I treated my child’s symptoms with these medicines: __Inhaler blue, tan, red/pink, red (circle all that apply) __Tylenol __Antibiotics __Advil __Other: _______________ My child got better in _____ days I did/did not go to the doctor because _______________________________________________ Other information that I want you to know: ______________________________________________________________________________________________ We are going to the clinic! Date: Time: I brought my child to the nurse practitioner/doctor today because____________________________________________________________________________________________________ My child has been sick for _________ days My child has been sick with (check all that apply) ___Cough ___Earache ___Fever ___Not able to sleep ___frequent night waking ___Runny Nose ___Tummy Ache/Vomit ___Blocked Nose ___Rash (itchy/not itchy) I could hear a wheeze/whistle (yes or no) ____________ I heard it worse (when breathing in or out)___________ The symptoms were worse in the (day or night) ________ I could see my child’s breathing change, it looked like: __ faster/heavier __neck sucking in __worried/anxious __ nostrils flaring __sitting like a tripod __other:_______ I treated my child’s symptoms with these medicines: __Inhaler blue, tan, red/pink, red (circle all that apply) __Tylenol __Antibiotics __Advil __Other: _______________ Other information that I want you to know: __________________________________________________________________________________________________________ My diagnosis was:________________________________________ My treatment was:_______________________________________ Date: Time: I brought my child to the nurse practitioner/doctor today because____________________________________________________________________________________________________ My child has been sick for _________ days My child has been sick with (check all that apply) ___Cough ___Earache ___Fever ___Not able to sleep ___frequent night waking ___Runny Nose ___Tummy Ache/Vomit ___Blocked Nose ___Rash (itchy/not itchy) I could hear a wheeze/whistle (yes or no) ____________ I heard it worse (when breathing in or out)___________ The symptoms were worse in the (day or night) ________ I could see my child’s breathing change, it looked like: __ faster/heavier __neck sucking in __worried/anxious __ nostrils flaring __sitting like a tripod __other:_______ I treated my child’s symptoms with these medicines: __Inhaler blue, tan, red/pink, red (circle all that apply) __Tylenol __Antibiotics __Advil __Other: _______________ Other information that I want you to know: __________________________________________________________________________________________________________ My diagnosis was:________________________________________ My treatment was:_______________________________________ Time to go to the hospital! Date: Time: I brought my child to the nurse practitioner/doctor today because____________________________________________________________________________________________________ My child has been sick for _________ days My child has been sick with (check all that apply) ___Cough ___Earache ___Fever ___Not able to sleep ___frequent night waking ___Runny Nose ___Tummy Ache/Vomit ___Blocked Nose ___Rash (itchy/not itchy) I could hear a wheeze/whistle (yes or no) ____________ I heard it worse (when breathing in or out)___________ The symptoms were worse in the (day or night) ________ I could see my child’s breathing change, it looked like: __ faster/heavier __neck sucking in __worried/anxious __ nostrils flaring __sitting like a tripod __other:_______ I treated my child’s symptoms with these medicines: __Inhaler blue, tan, red/pink, red (circle all that apply) __Tylenol __Antibiotics __Advil __Other: _______________ Other information that I want you to know: __________________________________________________________________________________________________________ My diagnosis was:________________________________________ My treatment was:_______________________________________ Date: Time: I brought my child to the nurse practitioner/doctor today because_______________________________________________ _____________________________________________________ My child has been sick for _________ days My child has been sick with (check all that apply) ___Cough ___Earache ___Fever ___Not able to sleep ___frequent night waking ___Runny Nose ___Tummy Ache/Vomit ___Blocked Nose ___Rash (itchy/not itchy) I could hear a wheeze/whistle (yes or no) ____________ I heard it worse (when breathing in or out)___________ The symptoms were worse in the (day or night) ________ I could see my child’s breathing change, it looked like: __ faster/heavier __neck sucking in __worried/anxious __ nostrils flaring __sitting like a tripod __other:_______ I treated my child’s symptoms with these medicines: __Inhaler blue, tan, red/pink, red (circle all that apply) __Tylenol __Antibiotics __Advil __Other: _______________ Other information that I want you to know: __________________________________________________________________________________________________________ My diagnosis was:________________________________________ My treatment was:_______________________________________ Notes: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ References Asthma Clinic (2014) About Asthma. Retrieved from http://www.cw.bc.ca/library/pdf/pamphlets /BCCH1108_AboutAsthma_2014.pdf on March 28, 2017. Brunekreef, B., Smit, J., de Jongste, J., Neijens, H., Gerritsen, J., Postma, D., . . . van Strien, R. (2002). The prevention and incidence of asthma and mite allergy (PIAMA) birth cohort study: Design and first results. Pediatric Allergy and Immunology, 13(s15), 55-60. doi:10.1034/j.1399-3038.13.s.15.1.x. Castro-Rodriguez, J. (2010). The asthma predictive index: A very useful tool for predicting asthma in young children. Journal of Allergy and Clinical Immunology, 126(2), 212-216. doi:10.1016/j.jaci.2010.06.032.
UBC Graduate Research
A Diary for Parents of Children with Suspected Asthma Harris, Jodi 2017-04
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