Aanmelden als patiënt | Nederlands Astmacentrum Davos

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, Max. file size: 128 MB.

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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