Patient name: |
DOB: |
|
Date of visit: |
Location of administration: |
|
Omalizumab dose: |
Date of first omalizumab administration: |
|
# of prior omalizumab injections: |
Last omalizumab administration date: |
|
Pre-administration Evaluation |
|
Blood pressure: |
Respiratory rate: |
|
Pulse: |
Temperature: |
|
Asthma control questionnaire |
|
How many times per week do you have asthma symptoms during the day? |
|
|
|
How many times per week do you have asthma symptoms at night? |
|
|
|
Has your asthma affected your ability to perform physical activities? |
|
|
|
How many asthma attacks have you had in the past week? Month? |
per week: __________ |
per month: _________ |
|
Has your asthma caused you to miss any work/school? |
|
|
|
How many times per week do you have to use your rescue inhaler? |
|
|
|
Spirometry results (if indicated) |
|
FEV1
|
FVC: |
|
Other results |
|
|
|
|
|
Post administration information |
|
Duration of post-administration observation |
|
|
|
Note any adverse reactions here: |
|
|