Chronic Care Programme Assessment Questionnaire
Chronic disease / Asthma
Date
Member surname / Initials
GetMed membership nr / GetMed plan
GetMed account nr / Option
Patient surname / Initials
Patient date of birth / Dependant code
Doctor name / Initials
Doctor practice number / Contact number
Assessment questions
  1. Was their any history or symptoms of allergies e.g. seasonal runny nose, recurrent sinusitis, eczema or known allergies to dust, food, animal hair etc?
/ Yes / No
  1. History of smoking: current smoker or stopped?
/ Yes / No, never smoked
  1. Was asthma previously diagnosed?
/ Yes / No
  1. Diagnosed how long ago?
/ < 1 year / 1 to 3 years / > 3 years
  1. Seen by a specialist?
/ Yes / No
  1. Had lung function tests done, how long ago was last one?
/ < 1 year / 1 to 3 years / > 3 years or never done
  1. A typical symptomatic event would include shortness of breath, wheezing and difficulty in breathing. How many such events would occur on average?
/ Less than twice a week / > twice a week but not every day / Every day almost never without symptoms
  1. If these symptomatic events occur at night, waking up the patient with the symptoms described, how often do they occur?
/ Twice a month or less / More than twice a month but not more than twice a week / More than twice a week
  1. On average, does the asthma as condition regularly limits normal daily activity such as walking, climbing stairs etc? How often does this happen?
/ Twice a month or less / More than twice a month but not more than twice a week / More than twice a week
  1. The puffer treatments used are:
  2. (if none leave open)
/ An inhaler like Ventolin or Venteze only / An acute puffer as well as a steroid puffer or a combination puffer / Combination puffer(s) with added oral medication such as regular tablets or bouts of cortisone tablets
  1. Describe puffer use.
  2. (Judge on: Shake, exhale, tilt head back, seal lips around inhaler, puff or inhale deeply, keep 10 counts before exhaling).
/ Correct technique / Grasp the concept but not used entirely correctly / No understanding or poor use
  1. What lifestyle changes has patient implemented since being diagnosed?
/ Stopped smoking & avoid allergens / Eliminated allergens such as pets, tress etc / No real changes
  1. Has patient used oral cortisone for asthma in the last year? If so how many times was this necessary?
/ Not in last 12 months / Once or twice / 3 times or more
  1. Was patient admitted to hospital for asthma in the last year?
/ Not admitted / Admitted once / Admitted more than once
  1. Was it ever necessary to treat on a ventilator, in ICU or High Care for your asthma (in last 3 years)?
/ Yes / No
  1. Do you feel controlled on your current medication?
/ Yes / No
  1. Do you use your medication daily as prescribed?
/ Yes / No
  1. PEF or VEF1 measurement values:
/ > 80% of the predicted value / 60% 80% of predicted value / < 60% of predicted value
  1. On auscultation are wheezes audible?
/ Yes / No
  1. Any sign of chronic airways disease?
/ Yes / No
  1. In terms of medication use would you describe the patient as:
/ Very compliant / Moderately compliant / Poor compliance
  1. In terms of lifestyle adaptation would you describe the patient as:
/ Very compliant / Moderately compliant / Poor compliance
  1. How would you assess the severity of the condition?
/ Mild / Moderate / Severe
For Office use
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Date