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

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
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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
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__________________________________________________________________________________
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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: _____________________________
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