Child Asthma Review (up to 12 years old)

Please use this form if you are aged up to 12 years old, if you are older than 12 you will need to complete the Adult Asthma Review form.

Child Asthma Review

Child Asthma Review

If you are human, leave this field blank.

Section

Asthma Control Score

Questions for Child

How is your asthma today? *

Very good - 3

Good - 2

Bad - 1

Very bad - 0

Not applicable

How much of a problem is your asthma when you run, exercise or play sports? *

It's not a problem - 3

It's a little problem but okay - 2

It's a problem and I don't like it - 1

It's a big problem, I can't do what I want to do - 0

Not applicable

Do you cough because of your asthma? *

No, none of the time - 3

Yes, some of the time - 2

Yes, most of the time - 1

Yes, all of the time - 0

Not applicable

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

No, none of the time - 3

Yes, some of the time - 2

Yes, most of the time - 1

Yes, all of the time - 0

Not applicable

Questions for Parent or Gurdian

During the last 4 weeks, how many days did your child have any daytime asthma symptoms? *

Not at all - 5

1-3 days - 4

4-10 days - 3

11-18 days - 2

19-24 days - 1

Everyday - 0

Not applicable

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

Not at all - 5

1-3 days - 4

4-10 days - 3

11-18 days - 2

19-24 days - 1

Everyday - 0

Not applicable

During the last 4 weeks, how many days did your child wake up during the night because of asthma? *

Not at all - 5

1-3 days - 4

4-10 days - 3

11-18 days - 2

19-24 days - 1

Everyday - 0

Not applicable

Calculated Asthma Control Score

Inhaler Technique

Please select the types of inhalers that you use:

Metered Dose Inhaler

Autohaler

Accuhaler

EasiBreathe Inhaler

Easyhaler

Turbohaler

Small Volume Spacer

Large Volume Spacer

My inhaler is not listed here

Please specify your inhaler:

Please watch these short video(s) on how to use your inhalers

Please let us know that you have watched and understood the video(s): *

I have watched and understood the video(s)

I have not watched the video(s)

I have watched the video(s) however I would like a further explanation

Asthma Care Plan

Do you have a care plan?

Yes

No

Please let us know your care plan: *

Additional Questions

Do you smoke?

Yes

No

How many cigarettes do you smoke in a day?

1 to 9

10 to 19

20 to 39

40 or more

Would you like to be seen by our smoking cessation adviser?

Yes

No

Are you exposed to tobacco smoke at home/in public places?

Yes

No

Number of exacerbations in the past year: *

Submit