1 home visit checklist for parent mentors initial ... - UT Southwestern
1 home visit checklist for parent mentors initial ... - UT Southwestern
1 home visit checklist for parent mentors initial ... - UT Southwestern
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6. PEAK FLOW METERS<br />
Does child have a peak flow meter (Please circle) Yes / No<br />
NA<br />
If no explain to <strong>parent</strong>s the importance of peak flow meters, instruct <strong>parent</strong> how to obtain<br />
one (call health care provider<br />
If yes, does the child use the peak flow meter when necessary (Please circle) Yes / No<br />
NA<br />
What is the child’s: Green zone: ________________<br />
Yellow Zone: ________________<br />
Red Zone:<br />
________________<br />
If no peak flow meter, family doesn’t regularly use peak flow meter, why<br />
Additional Comments<br />
______________________________________________________________________<br />
______________________________________________________________________<br />
______________________________________________________________________<br />
______________________________________________________________________<br />
______________________________________________________________________<br />
______________________________________________________________________<br />
Parent Mentor Review (place a check next to those discussed with <strong>parent</strong>; if something doesn’t<br />
apply put “NA” in the box)<br />
When/how to use a peak flow meter<br />
Peak flow chart<br />
How to track peak flow results<br />
How to clean peak flow meter<br />
How to obtain new peak flow meter if lost or broken<br />
Special recommendations from the child’s primary care provider<br />
7. TRIGGERS<br />
What are some things that make your child have an asthma attack (Check all that apply)<br />
Tobacco Smoke<br />
Mold<br />
Strong Smells<br />
Pets<br />
Dust<br />
Exercise<br />
Foods<br />
Cockroaches<br />
Dust mites<br />
Colds or Flu<br />
Pollution<br />
Grass<br />
Flowers<br />
Trees<br />
Humidity<br />
Cold or hot weather (temperature changes)<br />
Ozone<br />
Heat<br />
Additional things that may make your child have an asthma attack<br />
_______________________________________________________________________________<br />
_______________________________________________________________________________<br />
_______________________________________________________________________________<br />
_______________________________________________________________________________<br />
3
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