Asthma Questionnaire

Patient's Name

Age

Date of Birth

1. How much does your child’s asthma bother or interrupt him/her during normal activities (playing, running around, and sports)?

Never Rarely Sometimes Often All of the time

2. How many times has your child been had urgent care or hospitalized for asthma in the past year?

0 times 1 times 2 times 3 times 4 times 5 or more times

If Food, please specify

If Other, please specify

b. ) Does your child have a life threatening allergy or anaphylaxis?

Yes No

If so, does s/he have an epi-pen at school?

Yes No

4. Characteristics of the home (circle all that apply)

Carpeting

Humidifier

Old home/mold

Wood-burning stove

A lot of upholstery/stuffed furniture

Stuffed animals in bed

5. Does anyone smoke in the home (tobacco, other inhaled substances that produce fumes)?

Yes No

6. How many days of school has your child missed in the past year due to asthma/respiratory problems

7. Describe the symptoms your child typically experiences before or during an asthma episode: (Check all that apply)

Coughing

Trouble breathing

Runny nose

Rubbing chin/neck

Breathing hard/fast

Clearing the throat

Feeling tired/weak

Wheezing

Other

If Other, Please specify

8. How well does your child take his/her asthma medications? (Check only one answer)?

Takes medicine by self Needs help taking medicine Not using medicine now

9. In the past 4 weeks, how often has your child used a rescue or reliever medicine (a syrup, inhaler, or breathing machine) to relieve coughing, trouble breathing, or wheezing?

Never 1-2 days/week 3 or more days/week but not everyday Everyday

10. In the past 4 weeks, how often has your child had coughing, trouble breathing, or wheezing in the morning or during the day?

Never 1-2 days/week 3 or more days/week but not everyday Everyday

11. In the past 4 weeks, how often has your child had coughing, trouble breathing, or wheezing at night while sleeping?

Never 1-2 times 3 or more times/month 2 or more times/week Every night

Current Medications: List or attach all medications taken routinely or on an as needed basis.

Add Additional Medication

Past Medications used for Allergy and Asthma (include oral and topical corticosteroids, antihistamines, inhalers and nose sprays)

Add Additional Medication

Allergies: include drug allergies, insects, environmental

Add Additional Allergies

Hospitalizations or ER visits in the past 5 years?

Add Additional Hospitalization

Family History

Asthma

Hay Fever

Food Allergy

Drug Allergy

Eczema

Hives

Headaches

What worries you about your child’s asthma?

What do you want to accomplish or learn at this visit?

What do you expect from treatment?

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Signature

Date

FOR STAFF USE:

Asthma Classification

Mild Intermittent

Mild persistent

Moderate persistent

Severe persistent

Peak flow technique

MDI technique

Review Action Plan

Daily meds

Emergency meds

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