Emergency Inhaler Use Notification Form
Report details of an emergency inhaler use incident to support timely care and follow-up.
Date and time of the incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Name of person who used the inhaler
*
First Name
Last Name
Your relationship to the person
*
Please Select
Self
Parent/Guardian
Teacher/School Staff
Coach
Other
Primary symptoms experienced
*
Shortness of breath
Wheezing
Coughing
Chest tightness
Other
Suspected trigger or cause
*
Physical activity/exercise
Allergens (pollen, dust, etc.)
Respiratory infection
Weather change
Unknown
Type of inhaler used
*
Salbutamol/Albuterol (blue reliever)
Other reliever
Unknown
Number of puffs administered
*
Response to inhaler
*
Immediate improvement
Partial improvement
No improvement
Worsened
Additional actions taken
*
Called emergency services (911)
Visited clinic/hospital
Monitored at home
Contacted healthcare provider
Other
Is follow-up or further medical attention needed?
*
Yes, follow-up is needed
No, resolved with inhaler
Unsure
Submit Notification
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