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40 Asthma Diary

The document is an asthma diary template that allows patients to track their asthma symptoms, medications, and contact information for their doctor. It includes spaces to log daily asthma symptoms using a scale of 1 to 10, medications taken each day including dose, and contact details for their doctor in case of an emergency. The diary covers a single month to enable patients to monitor their asthma over time with their doctor.

Uploaded by

Mohammed Mian
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
1K views1 page

40 Asthma Diary

The document is an asthma diary template that allows patients to track their asthma symptoms, medications, and contact information for their doctor. It includes spaces to log daily asthma symptoms using a scale of 1 to 10, medications taken each day including dose, and contact details for their doctor in case of an emergency. The diary covers a single month to enable patients to monitor their asthma over time with their doctor.

Uploaded by

Mohammed Mian
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ASTHMA DIARY

http://www.allergyfoundation.co.za

ASTHMA DIARY
ASTHMA DIARY
ASTHMA DIARY ASTHMA DIARY
E NAME
NAME NAME
MEDICATION/ Dose
ATION/ Dose
CATION/ Dose
MEDICATION/ Dose MEDICATION/ Dose

ller
r Controller
Controller Controller Your doctor: Your doctor:
Your doctor: Your doctor: You

Contact details
Contact detailsContact details
Contact details Con
er Reliever Reliever Tel:
Tel: Tel:
Tel: Tel:

Tel:
Tel: Tel:
Tel: Tel:

Other Other

fold

NAME MONTH:______________________________________________
MONTH:______________________________________________
MONTH:______________________________________________
MONTH:______________________________________________
MONTH:______________________________________________

SMS SYMPTOMS
SYMPTOMS 1 1 2 2 3 3 4 41
SYMPTOMS
1 5 522 6 633 7 744 8 855 9 96610 107711 118812 129913 13
10
1 14 14
10 11
2 15 15
11 12
3 16 16
12 13
4 17 17
13 14
5 18 18
14 15
6 19 19
15 16
7 20 20
16 17
8 21 21
17 18
9 22 22
18 10
1923 23
19 11
2024 24
20 12
2125 25
21 13
2226 26
22 14
2327 27
23 15
2428 28
24 16
2529 29
25 17
2630 30
26 18
2731 31
27 19
28
28 20
29 30
29 21
30 31
22
31 23 24
MEDICATION/ Dose
day cough - day
cough - day cough - day
night
ht Controller
cough - night
cough - night cough - night Your doctor:
/ tight chest
ght chest wheeze / tight chest wheeze / tight chest
wheeze / tight chest
er
ever used reliever used reliever
Contact details
used reliever
Reliever
pital visit for nebuliser
ospital visit for nebuliser
clinic / hospital visit for nebuliser
clinic / hospital visit for nebuliser
clinic / hospital visit for nebuliser Tel:

er Controller dayday day Controller day Tel:


Controller day
night
night night night
Other night
other dayday day other day
other day
night
night night night
night

NAME MONTH:______________________________________________
SYMPTOMS
MEDICATION/ Dose 1 MONTH:______________________________________________
2 3 4 5 6 7 8 9 10 11
MONTH:______________________________________________
MONTH:______________________________________________ 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
MONTH:______________________________________________ 29 30 31
SMS SYMPTOMS 1 1 2 2 3 3 4 4 SYMPTOMS
1 5 5 2 6 6 3 7 7 4 8 8 5 9 9 610 10711 11812 12913 1310
1 14 1411
2 15 1512
3 16 1613
4 17 1714
5 18 1815
6 19 1916
7 20 2017
8 21 2118
9 22 2210
1923 2311
2024 2412
2125 2513
2226 2614
2327 2715
2428 2816
2529 2917
2630 3018
2731 3119
28 20
29 21
30 22
31 23 24
cough - day
day cough - day cough - day
night
ht Controller
cough - night
cough - night cough - night Your doctor:
/ tight chest
ght chest wheeze / tight chest wheeze / tight chest
wheeze / tight chest
er
ever used reliever used reliever Contact details
pital visit for nebuliser
ospital visit for nebuliser
clinic / hospital visit for nebuliser
used reliever clinic / hospital visit for nebuliser

er
Reliever
clinic / hospital visit for nebuliser
Controller dayday day Controller day
Tel:
night
night night night
other dayday day other day Tel:
Controller night
night day
night night

Other night
other day
MONTH:______________________________________________
MONTH:______________________________________________
MONTH:______________________________________________
MONTH:______________________________________________
SMS SYMPTOMS 1 1 2 2 3 3 4 4 SYMPTOMS
night 1 5 5 2 6 6 3 7 7 4 8 8 5 9 9 610 10711 11812 12913 1310
1 14 1411
2 15 1512
3 16 1613
4 17 1714
5 18 1815
6 19 1916
7 20 2017
8 21 2118
9 22 2210
1923 2311
2024 2412
2125 2513
2226 2614
2327 2715
2428 2816
2529 2917
2630 3018
2731 3119
28 20
29 21
30 22
31 23 24
day fold cough - day cough - day
night
ht cough - night cough - night
/ tight chest NAME
ght chest wheeze / tight chest MONTH:______________________________________________
wheeze / tight chest
er
ever used reliever used reliever
SYMPTOMS
MEDICATION/ Dose
pital visit for nebuliser
ospital visit for nebuliser
clinic / hospital visit for nebuliser 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
clinic / hospital visit for nebuliser 29 30 31
cough - day
er Controller dayday day Controller day
Controller
cough - night night
night night night Your doctor:
other dayday day other day
wheeze / tight chest
night
night night night Contact details
used reliever
Reliever
clinic / hospital visit for nebuliser Tel:
MONTH:______________________________________________
MONTH:______________________________________________
MONTH:______________________________________________ MONTH:______________________________________________
SMS SYMPTOMS 1 1 2 2 3 3 4 4 SYMPTOMS
1 5 5 2 6 6 3 7 7 4 8 8 5 9 9 610 10711 11812 12913 1310
1 14 1411
2 15 1512
3 16 1613
4 17 1714
5 18 1815
6 19 1916
7 20 2017
8 21 2118
9 22 2210
1923 2311
2024 2412
2125 2513
2226 2614
2327 2715
2428 2816
2529 2917
2630 3018
2731 3119
28 20
29 21
30 22
31 23 24
day cough - day cough - day Tel:
night
ht Controller
cough - night day cough - night
/ tight chest
ght chest wheeze / tight chest
Other night wheeze / tight chest
er
ever used reliever used reliever
other
pital visit for nebuliser
ospital visit for nebuliser
clinic / hospital visit for nebuliser day clinic / hospital visit for nebuliser
night
er Controller dayday day Controller day
night
night night night
other dayday day MONTH:______________________________________________
other day
night
night night night
SYMPTOMS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
cough - day
cough - night
wheeze / tight chest
used reliever
clinic / hospital visit for nebuliser

Controller day
night
other day
night

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