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A Diary for Parents of Children with Suspected Asthma Harris, Jodi Apr 30, 2017

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  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.                                                                                                          

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