Asthma Medication Refill Request Form

Managing asthma requires consistent medication and regular monitoring. This Asthma Medication Refill Request Form helps healthcare practices, pulmonology clinics, and primary care providers streamline the refill process while ensuring patient safety and proper asthma control.

Built with Paperform, this template goes beyond basic prescription requests. It captures essential clinical data including peak flow meter readings, symptom tracking, and inhaler technique self-assessment—helping providers make informed decisions about refills and identify patients who may need additional intervention.

Key features for healthcare providers:

• Automated clinical decision support: Conditional logic triggers pulmonologist consultation recommendations based on peak flow readings, symptom frequency, or rescue inhaler overuse
• Comprehensive symptom tracking: Monitor daytime and nighttime symptoms, activity limitations, and emergency medication use to assess asthma control
• Inhaler technique validation: Self-assessment questions help identify patients who may benefit from technique education or spacer devices
• Medication adherence monitoring: Track current medications, refill timing, and barriers to adherence

For practices looking to enhance their workflow automation, this form integrates seamlessly with Stepper to route refill requests to the appropriate provider, flag urgent cases, update your EHR system, and trigger follow-up appointment scheduling when clinical indicators warrant additional care.

The form's conditional logic ensures patients with poorly controlled asthma receive appropriate escalation—whether that's a nursing callback, an in-person visit, or a pulmonologist referral—while straightforward refills move efficiently through your system.

Trusted by healthcare practices nationwide and designed with patient safety in mind, this template helps you maintain quality asthma care while reducing administrative burden on your clinical staff.