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Child Asthma Review

Please complete the form below to calculate your Asthma control

Name: *

Email: *

Date of Birth(DD-MM-YYYY): *

Phone:

Which Surgery are you registered at?

Have your child answer the following questions:

None

1. How is your asthma today?

Very Bad Bad Good Very Good

2. How much of a problem is your asthma when you exercise or play sports?

It's a big problem, I can't do what I want to do It's a problem and I don't like it It's a little problem but its ok It's not a problem

3. Do you cough because of your asthma?

Yes, all of the time Yes, most of the time Yes, some of the time Non, none of the time

4. Do you wake up during the night because of your asthma?

Yes, all of the time Yes, most of the time Yes, some of the time No, none of the time

Please complete the following questions on your own:

5. During the last 4 weeks, how many days did your child have day time asthma symptoms?

Not at all 1-3 days 4-10 days 11-18 days 19-24 days Everyday None

6. During the last 4 weeks, how many days did your child wheeze during the day because of asthma?

Not at all 1-3 days 4-10 days 11-18 days 19-24 days Everyday None

7. During the last 4 weeks, how many days did your child wake up in the night because of asthma?

Not at all 1-3 days 4-10 days 11-18 days 19-24 days Everyday None

Time's up

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