Referral Form

(We are only accepting Referrals for the Following Cities: Salem, Lynn, Peabody, MA)
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    Asthma Action Plan
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    Patient Demographic Information

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    Referring Agency Information

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    Reasons for Referal:

    Missed School/work due to Asthma in the past 6 Months
    Hostipital Admission for Asthma exacerbation in the last 12 Months
    Repeated ER or urgent care visit for asthma in last 12 months
    Overuse or rescue medication in last 6 months
    More than one course of oral steroids in last 6 months
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    Concern about home environmental triggers:

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    Positive Allergy testing result to:

    Allergy test conducted?
    Pollen
    Dust Mites
    Roaches
    Mice
    Animal Dander
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    Equipment Used:

    Nebulizer-Mouthpiece
    Peak Flow Meter
    Spacer
    Inhaler
    Nebulizer-MaskĀ 
    Oxygen Machine
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