Respiratory Episode Observation Log Form
Use this form to log and track details of respiratory episodes. Please complete each field as accurately as possible.
Date and Time of Episode
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Observed Symptoms
*
Shortness of breath
Coughing
Wheezing
Chest tightness
Rapid breathing
Other
Severity of Episode
*
Mild
Moderate
Severe
Possible Triggers
Allergens
Physical activity
Cold air
Infection
Unknown
Other
Duration of Episode (minutes)
Actions Taken
Rested
Used inhaler/medication
Called for help
No action needed
Other
Outcome of Episode
Resolved without intervention
Resolved after intervention
Required medical attention
Observer Name
First Name
Last Name
Relationship to Individual
Please Select
Self
Parent/Guardian
Caregiver
Teacher/Staff
Other
Additional Notes (optional)
Submit Log
Should be Empty: