Asthma Assessment Form Page 2
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47. Does your child have a spacer for home use and one for school/daycare?
Yes
No
8. Do you need another spacer/valved holding chamber today?
Yes
No
9. Do you have an updated asthma action plan?
Yes
No
10. How many times in the last 12 months has your child:
Received oral steroids for difficulty breathing, coughing, chest tightness and wheezing
(1 – 2 times)
(3 – 4 times)
(5 or more times)
Gone to the doctor for a walk-in/urgent care visit for asthma
(1 – 2 times)
(3 – 4 times)
(5 or more times)
Gone to the emergency room at the hospital for asthma
(1 time)
(2 times)
(3 or more times)
Stayed overnight at the hospital?
(1 time)
(2 times)
(3 or more times)
Missed school due to asthma symptoms?
(1-5) days
(6-10 days)
(11 or more days)
11. Has your child ever been diagnosed with asthma by any doctor they have seen in the past?
Yes
If Yes, at what age?______________________________________
No
12. Check all the symptoms you have noticed since your child started having trouble breathing.
Cough
Wheeze
Difficulty breathing while being still
Difficulty breathing with exercise/running: coughing, tightness of chest, easily out of breath
Difficulty breathing at night: cough, chest tightness or wheezing during the night
If so, when did these symptoms start?
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
13. What is the child’s level of smoke exposure? (Select all that apply)
None
Family/caregivers smoke inside home
Family/caregivers smoke in vehicle
Family/caregivers smoke outside only
14. During which time of the year does your child have the most difficulty breathing, coughing, wheezing,
chest tightness?
Fall
Winter
Spring
Summer
All Year Round
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