Asthma Follow Up Questionnaire

Please correct the errors described below.

Please help our practice improve the care we provide your child with asthma. Our goal is for your child to be symptom free, sleep well and participate in all activities. Your nurse or doctor will review these questions with you.


In the past 4 weeks how frequently has your child:

Examples: Albuterol, Xopenex, Proair, Proventil, Ventolin



In the past 12 months was your child:



During the past month is your child taking any DAILY control medicines for Asthma or Allergic Rhinitis (Atopy)?

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In our effort to improve patient care, please read the following.

Previously we treated your child for asthma symptoms.

During the past 12 months has your child:

  1. Coughed now and then for no good reason?
  2. Coughed when laughing?
  3. Coughed with aerobic exercise?
  4. Taken any medicines using an inhaler (By mouth not nose) or a nebulizer?

If yes to any of these questions, then please complete the form on the other side.

If no, then return this form to the nurse.

Thank you!

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