Respiratory Emergency Assessment Form
Complete this assessment to evaluate the current respiratory emergency scenario. Please answer all questions accurately to ensure a thorough evaluation.
Patient Age Group
*
Infant (0-1 year)
Child (1-12 years)
Adolescent (13-17 years)
Adult (18-64 years)
Older Adult (65+ years)
Main Respiratory Symptoms (select all that apply)
*
Shortness of breath
Cough
Wheezing
Chest tightness
Stridor
Other
Symptom Onset and Duration
*
Sudden (within minutes)
Acute (within hours)
Subacute (within days)
Chronic (over weeks or longer)
Symptom Severity (at its worst)
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Observed Breathing Pattern or Signs
*
Normal
Rapid breathing (tachypnea)
Labored breathing (use of accessory muscles)
Cyanosis (bluish lips/skin)
Grunting
Nasal flaring
Other
Known Trigger or Exposure
*
Allergen (pollen, dust, animal)
Infection (cold, flu, pneumonia)
Exercise
Smoke or fumes
Unknown
Other
Current Medications or Inhaler Use
*
No current medications
Regular inhaler use
Rescue inhaler used for this episode
Oral medications (steroids, antibiotics)
Other
Prior Respiratory History
*
No prior respiratory conditions
Asthma
COPD
Frequent bronchitis or pneumonia
Other chronic lung disease
Other
Urgent Warning Signs Present
*
Severe difficulty speaking
Bluish lips or face
Altered level of consciousness
Chest pain
None of the above
Recommended Follow-up / Triage Action
*
Immediate emergency intervention required
Urgent medical evaluation recommended
Monitor and follow-up with primary care
Self-care with provided instructions
Submit Assessment
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