BREATHE 1-2-3 Application Form
Child's Name
First Name
Last Name
Nickname (preferred name)
Age
Grade
Allergies
Age first diagnosed with asthma
Last hospital visit due to asthma
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Email
example@example.com
Parent/Guardian Cell
Please enter a valid phone number.
Family Physician
Physician's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reliever (blue)
Reliever dose
Controller (orange)
Controller dose
Other Medication
Do you currently have an asthma action plan?
Yes
No
Unsure
T-shirt size for child
Small
Medium
Large
BC Lung Foundation would like to record the Zoom session for the purpose of evaluating and revising the program, and will only share this with the development team. By signing below, you are consenting to the session being recorded. If you have any questions, contact Menn Biagtan at biagtan@bclung.ca.
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