Better Breathing Grant Program Comprehensive Asthma Assessment Form

Thank you for your interest in the Better Breathing Grant Program. To properly evaluate your application and provide you with the most appropriate assistance, please complete this detailed assessment of your asthma history and current status.

All information provided is confidential and will be used solely for the purpose of evaluating your eligibility for the Better Breathing Grant Program.

Contact Preference

Surname

Additional Info

Personal Information

Full Name:

Date of Birth:

Phone Number:

Email Address:

Home Address:

Current Insurance Provider:

Policy/Member Number:

Primary Care Physician:

Current Pulmonologist/Asthma Specialist (if applicable):

Asthma Diagnosis History

Your Current Age (Required):

1. At what age did you first experience asthma symptoms?

2. At what age were you officially diagnosed with asthma?

3. How was your asthma initially diagnosed? (Check all that apply)

Doctor's evaluation of symptoms

Pulmonary Function Test (PFT)

Bronchoprovocation test (methacholine challenge)

Peak flow monitoring

Response to asthma medications

Other:

4. Have you ever had lung function testing/pulmonary function testing (spirometry)?

Yes

Unsure

5. If yes, please provide details of your most recent pulmonary function test:

Date:

Location/Facility:

Results (if known):

FEV1:

FVC:

FEV1/FVC ratio:

Was there significant improvement after bronchodilator?

Yes

Unsure

6. Do you have copies of any previous lung function tests?

Yes (Please bring copies)

Smoking History

7. Smoking status:

Never smoked

Former smoker

Current smoker

8. If you have smoked:

Age started smoking:

Age quit smoking (if applicable):

Average packs per day:

Total pack-years (approx):

9. Have you used e-cigarettes or vaping products?

Never

Former user

Current user

If used, please specify frequency and duration:

Asthma Severity and Control

11. How would you rate your asthma control over the past 4 weeks?

Well-controlled (symptoms ≤2 days/week, no nighttime awakenings, no interference with normal activity)

Not well-controlled (symptoms >2 days/week, nighttime awakenings 1-3×/month, some limitation)

Very poorly controlled (symptoms throughout the day, nighttime awakenings ≥4×/month, extremely limited activity)

13. How many days of work/school have you missed due to asthma in the past year?

Asthma Symptoms & Related Conditions

14. Which symptoms do you typically experience during an asthma flare? (Check all that apply)

Wheezing

Shortness of breath

Chest tightness

Coughing

Increased mucus/sputum production

Difficulty sleeping

Other:

15. Do you have a history of any of the following? (Check all that apply)

Nasal polyps

Chronic sinusitis

Allergic rhinitis

Eczema/atopic dermatitis

Food allergies

Aspirin sensitivity

GERD (acid reflux)

Vocal cord dysfunction

Emergency Care and Hospitalizations (Past 2 Years)

18. How many times have you visited an urgent care center for asthma?

19. Please list dates and locations of urgent care visits in the past year (if applicable):

Visit 1: Date: Facility:

Visit 2: Date: Facility:

Visit 3: Date: Facility:

20. How many times have you visited an emergency room for asthma?

21. Please list dates and locations of emergency room visits in the past year (if applicable):

Visit 1: Date: Hospital:

Visit 2: Date: Hospital:

Visit 3: Date: Hospital:

22. How many times have you been hospitalized for asthma?

23. Please list hospitalizations for asthma in the past 2 years (if applicable):

Hospitalization 1:

Date: Hospital:

Duration: ICU? Y N Unsure Intubated? Y N Unsure

Hospitalization 2:

Date: Hospital:

Duration: ICU? Y N Unsure Intubated? Y N Unsure

Hospitalization 3:

Date: Hospital:

Duration: ICU? Y N Unsure Intubated? Y N Unsure

24. Do you have copies of any previous hospitalization records for asthma?

Yes (Please bring copies)

Current and Recent Medications

25. Please list ALL current asthma medications (inhalers, pills, biologics, nebulizers):

26. Albuterol rescue inhaler use:

≤2 days per week

>2 days per week but not daily

Daily

Multiple times per day

Unsure

27. In the past 2 years, have you experienced any gaps in your asthma medication treatment?

Yes

Unsure

28. If yes, please explain the reason for the gap(s) and duration:

29. Have you used oral steroids (prednisone, Medrol, etc.) for asthma in the past 2 years?

Yes

Unsure

30. If yes, please provide details:

31. Oral corticosteroid use in the past year:

No oral steroids in the past year

Prescribed oral steroids times for 3 or more days at a time

Currently on continuous daily oral steroids for months

Current daily dose (if applicable):

32. Have you ever used a biologic medication for your asthma?

Yes

Unsure

33. If yes, please list biologic medications used:

Allergy History and Testing

34. Do you have diagnosed allergies?

Yes

Suspected but not confirmed

35. If yes, please list your known allergens if available:

36. Have you ever had allergy testing?

Yes - skin testing

Yes - blood testing

Unsure

37. If yes, when and where was testing performed?

Date:

Provider/Facility:

38. Do you have any documentation of previous allergy test results?

Yes (Please bring copies)

Laboratory Testing

39. Have you had a complete blood count (CBC) with eosinophil count in the past year?

Yes

Unsure

40. If yes, please provide details if known:

Date:

Eosinophil count:

41. Have you had an IgE level checked?

Yes

Unsure

42. If yes, result if known:

Result:

Date:

43. Have you had FeNO (exhaled nitric oxide) testing?

Yes

Unsure

44. If yes, result if known:

Result:

Date:

Insurance and Medication Access

46. Have you experienced any of the following issues with your asthma medications? (Check all that apply)

Insurance denials

High copays

Prior authorization delays

Formulary exclusions

Step therapy requirements

Pharmacy not stocking needed medications

Transportation issues getting to pharmacy

Other:

47. Approximately how much do you spend out-of-pocket monthly on asthma medications? $

48. Have you previously applied for or received assistance from any medication assistance programs?

Yes

Unsure

49. If yes, please list programs and outcomes:

Additional Information

50. Is there anything else about your asthma history or current situation that you feel is important for us to know when considering your application? (Required)

Agreement

I certify that the information provided in this form is accurate and complete to the best of my knowledge. I understand that providing false information may result in denial of assistance. I authorize Advanced Asthma Clinic to verify any information provided and to contact healthcare providers listed for additional information if needed.

Please check this box to agree.

Your Full Name (Required - Serves as agreement):

Please enter your full name to signify agreement.

Date of Agreement (Required):

Please enter today's date.

Please remember to bring copies of the following to your appointment if available:

Your insurance card (front and back)
Any recent pulmonary function test results
Recent laboratory results related to your asthma (Eosinophils, IgE if available)
A complete list of current medications

You may be contacted for additional information or documentation as needed.

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