Asthma Control Assessment & Management Plan (Pediatric)

Date: [Date]

Patient: [Patient name]

Age: [Age]

Provider: [Provider name, credentials]

Visit Reason: [Brief reason for visit]

Historian: [Self / Parent / Caregiver] (If not patient, note relationship)

Interval History and Control Assessment

[Interval summary paragraph] (Summarize asthma context, interval since last visit, and overall control impression. Note key changes in symptoms, therapy, or life context.)

Control Domains (past 2–4 weeks): [Daytime symptoms frequency] | [Nighttime awakenings] | [Reliever use frequency and context] | [Activity limitation including exercise-induced symptoms] (Use time-anchored statements for each domain. If any domain not assessed, state "not assessed.")

Risk Factors (past 12 months): [Exacerbations requiring systemic steroids] | [Urgent care/ED visits] | [Hospitalizations] | [Near-miss events if any] (Include counts and approximate dates. State "none" or "not assessed" as appropriate.)

Control Score: [ACT / cACT / not administered] [Score and date if administered]

Current Medications and Adherence

Regimen: [Controller(s) and reliever(s) with dose, device, and schedule] (Note spacer/nebulizer use. Include recent systemic steroid courses and relevant adverse effects if any.)

Adherence: [Estimated adherence and specific barriers identified] (If not assessed, state "not assessed.")

Technique: [Device(s) observed today, key errors identified, teaching provided] (If not observed, state reason and plan.)

Triggers and Relevant Comorbidities

[Relevant exposures: smoke/vaping, allergens, exercise, weather, viral patterns] (Include only those driving today's counseling.)

[Comorbidities affecting control today: allergic rhinitis, obesity, GERD, anxiety] (Include only if clinically relevant to this visit; omit stable unrelated conditions.)

Objective

Vitals: [Temp, HR, RR, SpO₂] (Include BP if obtained. Include growth parameters if monitoring ICS effects.)

Exam: [General appearance and work of breathing] | [Respiratory findings: air movement, wheeze, retractions, accessory muscle use] | [Pertinent ENT/skin findings] (Do not auto-populate normal values.)

Pulmonary Function Testing: [Spirometry: FEV₁, FVC, FEV₁/FVC with % predicted; bronchodilator response if done; quality statement] | [FeNO: value in ppb with interpretation] (Omit this section entirely if no testing performed or reviewed.)

Assessment

Asthma Control Classification: [Well controlled / Not well controlled / Very poorly controlled / Unable to classify] (State explicit basis: symptom frequency, nighttime awakenings, reliever use, activity limitation, exacerbation history, control score, and objective data. If data insufficient, specify what is missing.)

Contributing Factors: [Key drivers of current control status: adherence barriers, technique errors, trigger exposures, comorbidities, access issues]

Differential Diagnoses: [Alternative diagnoses under consideration] (Include only if atypical features or poor response despite optimized therapy; otherwise omit.)

Plan

Therapy: [Current step and step change if any, with rationale tied to assessment] | [Controller and reliever medications with dose, device, instructions] (If using ICS–formoterol as reliever, include maximum daily inhalations. For oral steroid burst, include indication, dose, duration, criteria for use.)

Trigger Mitigation: [Targeted recommendations linked to identified exposures and sensitizations] (Avoid generic boilerplate.)

Education: [Technique teaching provided] | [Adherence interventions discussed]

Asthma Action Plan: [Reviewed / Updated / Provided today / Not provided] (If not provided, state reason and plan. Note distribution: parent, school, daycare as applicable.)

Follow-up: [Interval based on control status and therapy changes] (Include timing for repeat spirometry, FeNO, or control score if indicated.)

Referrals: [Pulmonology / Allergy / Other] (Include only if placed today; otherwise omit.)