Pediatric Asthma Mortality Report

CONFIDENTIAL

This form should be completed for the death of a child who has been diagnosed with asthma pr whose cause of death was related to asthma. Medical examiners, coroners and persons who report deaths or sign death certificates should report pediatric asthma deaths to the Department of Public Health, Chronic Disease Prevention Section within 10 days of a pediatric asthma death occurrence. Complete this form in its entirety and attach a copy of the case records. if submitting information from a non-medical facility, omit the clinical section.


Death certificate number	Hospital Chart Number

Demographics of the deceased
Name	Date of Birth (mm/dd/yyyy) //
Race(select all that apply):
White Or Caucasain	Native Hawaiian/ Pacific Islander
Black Or African American	Multiracial
Unknown	American Indian/ Alaska Native
Other
Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown
Deceased Address (street, city, state, zip)
Residence County	Residence State(if not GA)
Name and Location of School (street, city, state, zip code)

Circumstances Preceding Death(acute presentation)

Name of adult witnessing start of asthma episode:
Last Name	First Name
Start of Asthma symptoms:
Date(mm/dd/yyyy) //	Time(HH:MM)
Place where asthma symptoms began Home of residence School Other Not Documented

Known or suspected exposure 24 hours prior to death(select all that apply)
Upper Respiratory Infection	Exercise
Pollen	Pets(Animal Dander)
Smoke	Stress
Not Documented	Other

Locality where death occurred

Place of death Home of residence Ambulance during EMS transport Emergency room Other Hospital Unknown

County	State(if not GA)

Clinical Information

Admission at Institution where death occurred or where it was reported
Date of admission(mm/dd/yyyy) //	Time of admission(HH:MM)
Date of death(mm/dd/yyyy) //	Time of death(HH:MM)
Status on admission(select all that apply)
Unconscious	Airway Obstruction
Respiratory Distress	Respiratory Arrest
Cardiac Arrest	Allergic Reaction
Seizures	Other
Condition on admission: Stable Dead on arrival Critically ill Other

Signs and symptoms(select all that apply):
Cyanotic	Respiratory Distress
Vomiting	Wheezing
Cough	Retractions
Abnormal Breath Sounds	Other
Asymptomatic	Not Documented

Viral Samples/labs ( to be completed later, once results are available)


Lab:			Result:


Interventions
Prior to arrival(select all that apply):
Albuterol	Levalbuterol	Epi-Pen
Cpr	Leukotriene	Aed
Inhaled Corticosteroid	Mast Cell Inhibitor	Otc Medication
Other
EMS(select all that apply):
Intubation	Cpr	Defibrillation
Chest Tube	Oxygen	Albuterol
Levalbuterol	Atropine	Epinephrine
Na Bicarb	Other
Emergency Department(select all that apply):
Intubation	Mechanical Ventilation	Bilevel Ventilation
Cpr	Defibrillation	Oxygen
Chest Tube	Other

Reported Patient History
Asthma medications prescribed in the past 12 months

Type	Number	Last date used

Releiver(i.e.:Albuterol)		Today Past 7 days Past 30 days
Controller(i.e.:Inhaled corticosteroids)		Today Past 7 days Past 30 days

Known Allergies(select all that apply):
Food	Pets	Insects
Evironmental	Unknown

Allergy History


Allergy	Date noted:	Type of test:
	//
Class/Severity	Anaphylaxis?	Epi pen?


No. of previous anaphylaxis episodes
History of comorbid conditions(select all that apply):
Prematurity	Cardiac Disease
Chronic Lung Disease Of Prematurity	Allergic Rhinitis/Sinusitis
Gerd	Obesity
Sleep Apnea	Aspirin/Nsaid Sensitivity
Eczema	Other
Smoke exposure(select all that apply):
Tobacco smoking	Past 7 days Past 30 days
Living with tobacco smoker	Past 7 days Past 30 days
Tobacco smoke exposure in car or home other than primary residence	Past 7 days Past 30 days
Current use of wood stove or fireplace	Past 7 days Past 30 days
Forest or brush fire smoke exposure	Past 7 days Past 30 days
No smoke exposure	Past 7 days Past 30 days

Medical/Psychological/Behavioral History


Type	No. of visists(past 2 months):	Chief Complaint:

Interventions	Diagnosis


Autopsy performed?	YesNo
Case Summary
Please provide a short summary of the events surrounding the death
This Form Completed By
Name	Title
Office/Dept.
Case Number(if assigned by reporting office)
Telephone --	Fax --
Date(mm/dd/yyyy) //	Checking this box you attest that the information is accurate to the best of your knowledge