Asthma Questionnaire – Child

If you have been advised by the surgery to submit a child asthma questionnaire please use this form. Depending upon the review, you will be contacted if you need to be seen in clinic for a further assessment. If symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

Please see the following websites for more information on Asthma that you may find useful:

Asthma Questionnaire - Child

Asthma Questionnaire - Child

Patient Details

Smoking

Do you smoke?

Asthma Symptoms - Please answer as accurately as you can

How often does asthma cause daytime symptoms?
How often does asthma cause night time symptoms?
How often does asthma limit activities?

Triggers

Please rank all that apply in order with 1 being the most regular trigger:

Has your asthma got significantly worse in the past year?
Have you had to go to A&E in the past year because of your asthma or been admitted to hospital?

Asthma Control Test – please base these answers on the last four weeks

How is your asthma today?
How much of a problem is your asthma when you run, exercise or play sports?
Do you cough because of your asthma?
Do you wake up in the night because of your asthma?
During the last 4 weeks, how many times did your child have any daytime asthma symptoms?
In future, we would like to email this questionnaire to you before your check-up. We need your consent to do this. Please choose the relevant option below. *