Table 3 Sample Omalizumab Patient Assessment Sheet

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: