About the Captain
You can be the one in control of your health, so we would like to get to know you, as the "Captain," a little better. Please print this form and fill in the missing information about yourself and place it in your Riley Hospital for Children Stay Active in Life (SAIL) at Indiana University Health binder.
First Name: ____________________ Male or Female: ____________________
Age: ____________________ Grade: ____________________
Who lives with you? List names and how they are related to you.
Who are positive support people for you in dealing with your asthma nutrition and physical activity? This can include parents, relatives, someone at school, a friend, doctor, nurse, etc. List as many as you can think of.
What do you like to do for fun?
What are your own asthma triggers?
What asthma medications do you have to take?
What do you like to do for exercise or physical activity?
Is there any activity that you would like to do but don’t feel that you can because of your asthma?
What is your favorite subject in school? ____________________
What is your least favorite subject in school? ____________________
What are your favorite foods?
Do you have any pets? List kind of pet and name ____________________
What do you want to be when you grow up? ____________________
List one unique thing about yourself: