1 home visit checklist for parent mentors initial ... - UT Southwestern

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Trigger/Environmental Control (Check all discussed with parent if not applicable put NA in box) Damp dust surfaces weekly Manage pests in the home Avoid food allergens Take steps to eliminate smoke in the home Medications taken before and attainable during exercise Vacuum carpeted areas and furniture at least once a week Pillow Covers Mattress covers Establish “pet free zones” Eliminate or wash heavy curtains Eliminate stuffed furniture from the child’s bedroom Avoid strong smells (perfumes, scented lotion, cleaning supplies, bleach) Keep areas free of water and dampness Get an annual flu shot Wash bedding in hot water weekly Change filters in air conditioners and humidifiers Keep child away from trees and outdoor triggers Keep windows shut and use air conditioners instead of fans Stay inside during very hot/cold temperatures Keep child away from fresh flowers Smokers in the home (Smoking Cessation) 8. ASTHMA AND SCHOOL/DAY CARE Have parents: Communicated asthma care plan with school/day care personnel Yes No Notified school/daycare personnel about medications taken during school/day care hours Yes No Given school/daycare emergency contact information Yes No Medications given at school/daycare Medication Name How much to take (dose) When to take Triggers: What are some things that make your child have an asthma attack at school/daycare (Check All that apply Stuffed Animals Pillows Dust on bookshelves and toys Classroom pets Plants or flowers Chalk dust Strong scents like 4
Trigger/Environmental Control at school/daycare (Check all discussed with parent if not applicable put NA in box) Stuffed animals Dust Plants or flowers Food Change in weather Pillows Classroom pets Chalk dust Exercise Strong scents Parent Mentor Review (place a check next to those discussed with parent; if something doesn’t apply put “NA” in the box) Importance of having asthma care plan at school Importance of notifying personnel about medications taken during school/daycare hours Exercise-induced asthma Comments _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 9. TRACKING REGULAR AND FOLLOW-UP APPOINTMENTS Does the child have a primary health care provider Yes No Does the child and family have regular scheduled visits for asthma Yes No Has the child and family missed any of their child’s routine visits for asthma Yes No If child and family have missed any appointments why/Comments __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Parent Mentor Review (place a check next to those discussed with parent; if something doesn’t apply put “NA” in the box) Importance of scheduled visits Identify contact information for health care providers (give families contact resource sheet) Identify next routine appointment with health care provider Identify monthly meeting with other asthma families 10. CARE PLAN AFTER ED VISIT AND HOSPITALIZATION Did family receive a care plan after ED visit or Hospitalization Yes No Does the child have an asthma specialist Yes No Date of the next follow-up appointment with health care provider: _____________________________ 5
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Page 3: 6. PEAK FLOW METERS Does child have

1 home visit checklist for parent mentors initial ... - UT Southwestern

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