Referral Form
(We are only accepting Referrals for the Following Cities: Salem, Lynn, Peabody, MA)
Primary Care Doctor Site:
Date of the Referral
MM
/
DD
/
YYYY
Client Agrees to Referral?
YES
NO
Client agrees?
Does your Client have an Asthma Action Plan?
If the answer is no, please go to the website and download the form.
YES
NO
Asthma Action Plan
Patient Demographic Information
Client/Child Name:
Your answer
Child/Client D.O.B:
Example 1/18/1985
Your answer
Guardian/Parent Name:
Your answer
Language:
Your answer
Address:
Example:73 Buffum St. Lynn, MA 01902 (We are only accepting Referrals for the Following Cities: Salem, Lynn, Peabody, MA)
Your answer
Contact Number:
Example (781) 595-7570
Your answer
Other Contact Number:
Example (781) 595-7570
Your answer
Type of Respiratory Diagnosis
Referring Agency Information
Referral is:
Agency Name:
Example: MA. Coalition for the Homeless
Your answer
Name of the worker:
Your answer
Agency Address:
Your answer
Contact Number:
Example: 781.595.7570 Ext. 0
Your answer
Email:
Your answer
Reasons for Referal:
1-3 Days
3-6 Days
6 or More Days
None
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
Concern about home environmental triggers:
Required
Additional Reasons for Referral
Positive Allergy testing result to:
YES
NO
Unknown
Allergy test conducted?
Pollen
Dust Mites
Roaches
Mice
Animal Dander
Equipment Used:
YES
NO
Nebulizer-Mouthpiece
Peak Flow Meter
Spacer
Inhaler
Nebulizer-Mask 
Oxygen Machine
Any Additional Concerns about your Referring client:
Example: Housing, Bed bugs, Pest Management, others...
Your answer
Submit
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