Asthma Referral Form

Form

September 02, 2026

Child Name

Birth Date

Sex

Physician Name
Clinic Name
Parent Name
Address Street

City

ZIP Code

Please skip entering any data on this field.

Phone Number
Asthma Risk Factors

Asthma control test score --

Asthma Control Test Score Input

Number of asthma-related ER visits in the last 12 months --

Number of ER Visits Input

Frequent rescue inhaler use

Nighttime awakenings

Exposure to second or third hand smoke

Socioeconomic risk factors

Frequent missed doctor visits

Difficulty understanding Asthma Action Plan

Environmental/housing concerns (mold dust, smoke, pets, pests, etc.)

Non-compliant medication management

Asthma interferes with activities of daily living

Inadequate communication with school

Frequent school absences related to illness

Check all that apply...

Additional/Relevant Data
Contact Name for Referral
Contact Email Address for Referral
Contact Phone Number for Referral

Client Aware of Referral?

Yes

Please attach below or send the following to St. Louis County Public Health Nurse:

St. Louis County North
201 South 3rd Ave W, Virginia, MN 55792

Phone: 218-471-7600 Fax: 218-471-7601

PublicHealth@stlouiscountymn.gov

St. Louis County South
320 W. 2nd St., 7W, Duluth, MN 55802

Phone: 218-725-5210 Fax: 218-725-5282

PublicHealth@stlouiscountymn.gov

Can attach current medication list, Asthma Action Plan, or release of information here. Files types accepted: images, PDF, video

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