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Davos Dutch Asthma Centre
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Admin-Nadavos2019
2019-05-23T08:11:33+02:00
Step 1 of 3
33%
Name of referring physician
Name of referring physician
*
Email address of referring physician
*
Institution / Hospital, other...
*
Patient information
Salutation
*
Ms/Mrs.
Mr.
Name
*
Date of birth
MM
DD
YYYY
CSN
*
Telephone number
*
Referral indication
1. Please describe in brief the reasons for your referral:
*
2. Describe the basis on which the diagnosis of asthma is made:
*
3. Does this concern a patient with serious asthma as per the definition from the NVALT guidelines?* Patient uses high dosage of ICS > 1000mcg equivalent of fluticasone and LABA?
*
Yes
No
4a. Is asthma control persistently poor?* ACQ > 1.5 or ACT < 19
*
Yes
No
4b. ACQ score:
*
4c. Has the patient had more than 2 exacerbations per year, for which OCS is prescribed?
*
Yes
No
4d. It is necessary to maintain treatment with OCS for > 6 per year?
*
Yes
No
4e. Hospital admissions over the past year?
*
Yes
No
Number of hospital admissions
*
5a. As part of this, has attention been paid to the following conditions?
*
Yes
No
5b. Inhalation technique is optimised?
*
Ja
Nee
5c. Therapy compliance is optimised?
*
Ja
Nee
5d. Exposure to exogenous irritants is minimised?
*
Ja
Nee
5e. Any comorbidity is given maximum treatment?
*
Ja
Nee
5g. Patient has been treated by pneumonologist and specialised nurse for at least 6 months?
*
Ja
Nee
5f. Patient does not smoke or has not smoked for ≥ 6 months?
*
Ja
Nee
5g. Patient has been treated by pneumonologist and specialised nurse for at least 6 months?
*
Ja
Nee
6a. What did it consist of?
*
7. Describe the relevant comorbidity in brief
*
8. Upload your medical correspondence here
Drop files here or
Accepted file types: jpg, gif, png, pdf, doc, docx, xls, xlsx.
9. Extra check
*
The patient named has given permission to send the above details to the Dutch Asthma Centre in Davos.
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