Asthma Referral Form
Form
June 28, 2026
Submit Asthma Referral Form
Child Name
Birth Date
Sex
F
M
Physician Name
Clinic Name
Parent Name
Address
Street
City
ZIP Code
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
No
Please attach below or send the following to St. Louis County Public Health Nurse:
Current medication list
Asthma Action Plan
Release of information
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
Submit
