APPENDIX 7 - ESSENTIAL NCD HEALTH INTERVENTION PROJECT – ASTHMA INITIAL ASSESSMENT FORM INITIAL ASSESSMENT
If yes go straight to the chart on page 4 of the asthma pocket protocol
and take appropriate action now.
Is the patient having an asthma attack now?
3. Has the patient noticed any factors that make their asthma worse?
4. On how many days over the past month (30 days, 4 weeks) did asthma interfere with normal day time activity or disturb sleep?
5. Over the past three months did the patient attend hospital because of an asthma attack and receive a nebuliser or an injection Year of diagnosis Year of diagnosis
7. Close family history (in 1st degree relatives) of:
4 Attack not severe and patient has taken 30mg prednisalone for 14 days
4 Attack not severe and patient has taken salbutamol for 48 hours
Prescribe patient 30mg prednisalone for 14 days
4 Attack not severe and patient is not taking bronchodilators daily
Prescribe patient salbutamol for 48 hours
Less than 10 days affected in the past month
More than 10 days affected in the past month
(in 3 months if on Step 1, otherwise next appointment is in 1 month)
*Definition of a severe attack A severe attack of asthma is when the patient is too breathless to complete sentences in one breath Respiratory rate ≥ 25 breaths per minute Heart rate ≥ 110 beats per minute APPENDIX 8 - ESSENTIAL NCD HEALTH INTERVENTION PROJECT – ASTHMA FOLLOW-UP FORM ASSESSMENT
If yes go straight to the chart on page 4 of the asthma pocket protocol
and take appropriate action now.
Is the patient having an asthma attack now?
3. On how many days over the past month (30 days, 4 weeks) did asthma interfere with normal day time activity or disturb sleep?
4. Over the past three months did the patient attend hospital because of an asthma attack and receive a nebuliser or an injection
If yes, give the number of occasions d d
Patient is having an acute attack:
4 Attack not severe and patient has taken 30mg prednisalone for 14 days
4 Attack not severe and patient has taken salbutamol for 48 hours
Prescribe patient 30mg prednisalone for 14 days
4 Attack not severe and patient is not taking bronchodilators daily
Prescribe patient salbutamol for 48 hours
Patient is not having an acute attack:
4 More than 10 days affected in the past month
(in 3 months if on Step 1, otherwise next appointment is in 1 month)
*Definition of a severe attack A severe attack of asthma is when the patient is too breathless to complete sentences in one breath Respiratory rate ≥ 25 breaths per minute Heart rate ≥ 110 beats per minute
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APPENDIX 7 - ESSENTIAL NCD HEALTH INTERVENTION PROJECT – ASTHMA INITIAL ASSESSMENT FORM 
APPENDIX 8 - ESSENTIAL NCD HEALTH INTERVENTION PROJECT – ASTHMA FOLLOW-UP FORM