Pediatric Asthma Severity Assessment
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The Pediatric Asthma Severity Assessment Form provides a structured clinical tool for evaluating and classifying asthma severity and control in pediatric patients, aligned with the National Asthma Education and Prevention Program (NAEPP) Expert Panel Report guidelines. It captures the key impairment and risk domain metrics including daytime symptom frequency, nighttime awakening episodes, short-acting beta-agonist (rescue inhaler) use, interference with normal activity, and spirometry or peak flow measurements when available. These data points map directly to the four-tier severity classification system — intermittent, mild persistent, moderate persistent, and severe persistent — that drives stepwise therapy decisions.
The template includes age-appropriate assessment sections that account for the differences in asthma presentation and management across developmental stages, from infants and toddlers (0-4 years) through school-age children (5-11 years) and adolescents (12+ years). It documents current controller and rescue medications with adherence assessment, identifies known asthma triggers including environmental allergens, respiratory infections, exercise, and irritant exposures, and captures vaccination status relevant to respiratory health. An asthma action plan section allows providers to document green/yellow/red zone parameters and corresponding medication instructions.
Designed for pediatric primary care offices, pediatric pulmonology clinics, allergy and immunology practices, emergency departments, and school-based health centers, this form supports consistent severity classification that drives evidence-based step therapy. It provides the documentation foundation needed for tracking asthma control over time, adjusting maintenance therapy, evaluating the need for specialist referral, and demonstrating quality metric compliance for asthma management programs.
What's included
- NAEPP-aligned impairment domain assessment for symptom frequency and activity limitation
- Age-stratified evaluation sections for infants, school-age children, and adolescents
- Four-tier severity classification with stepwise therapy mapping
- Current medication inventory with adherence assessment
- Trigger identification checklist and asthma action plan documentation
- Peak flow or spirometry recording and vaccination status
- Medical conditions checklist
- E-signature capture
- Structured medication list with dosage and frequency tracking
Who uses this template
- Pediatric primary care asthma severity classification and step therapy initiation
- Pediatric pulmonology clinic serial asthma control monitoring and treatment adjustment
- Emergency department acute asthma exacerbation evaluation and discharge planning
- School-based health center asthma management and action plan documentation
All form fields
14 fields across 2 pages. Customize any field after signing up.
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