Skip to content
Search for:
Davos Dutch Asthma Centre
High-altitude treatment
About us
Team of specialists
Working in the Davos Dutch Asthma Centre
Network
Patient
Patient with asthma
Treatment plan
Practical information
Refferal
Refferal
Referral information
Information
Scientific research
Results
Publications
Compliment, complaint or question
Contact us
Sign up
English
Nederlands
Loading...
Aanmelden als verwijzer
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.
