NORTH HANOVER TOWNSHIP SCHOOLS
Burlington County, New Jersey
ASTHMA QUESTIONNAIRE
Student’s Name ____________________________________ School Year ________________
School _____________________________ Grade ______ Teacher _______________________
In reviewing your child’s medical information, there is an indication of an asthma diagnosis.
The following information is helpful in determining any special needs your child may have as
related to his/her asthma. Please answer the questions to the best of your ability.
Thank you for your help as we work together to ensure your child has the healthiest learning
environment possible. If you have any questions or concerns, please call your school nurse.
1. How long has your child had asthma? _____________________________
2. Please rate the severity of his/her asthma. (circle)
(not severe)
1 2 3 4 5 6 7 8 9 10 (severe)
3. Please list any medications your child takes for asthma (everyday and as needed)
Name of medication
dose
frequency
In school _____________________________________________________________
_____________________________________________________________
At home _____________________________________________________________
______________________________________________________________
_______________________________________________________________
If your child will need to take asthma medication at school, the enclosed Asthma Action Plan
must be completed by your child’s health care provider. The medication (and tubing or spacer if
necessary) must be brought to the school nurse by a parent in the pharmacy labeled prescription
container. NO MEDICATION MAY BE BROUGHT TO SCHOOL BY A STUDENT!
4. Does your child have any side effects from his/her asthma medication? ________________
__________________________________________________________________________
5. How many days would you estimate he/she missed school last year due to asthma? ________
6. How many times has your child been treated in the emergency department for asthma in the
past year? ________________________________________________________________
7. How many times has your child been hospitalized overnight or longer for asthma in the past
year? ____________________________________________________________________
8. How often does your child see his/her doctor for routine asthma evaluations? ____________
9. What triggers your child’s asthma attacks? (please check all that apply)
___illness
___emotions
___ fresh cut grass
___foods
___weather
___exercise
___ cigarette or
___chemical odors
___fatigue
___ perfumes
other smoke
___ pet dander
Allergies (please list) _____________________________________________________
Other (please list)
_____________________________________________________
10. What does your child do at home to relieve wheezing during an asthma attack? (please
check all that apply)
_____breathing exercise
Takes medication
____inhaler
_____ rest/relaxation
____ nebulizer
_____ drinks liquids
____ oral medication
Other (please describe) ____________________________________________________
11. Do you know your child’s baseline peak flow rate?
Yes
No
Rate _______________________________
12. Does your child need any special considerations related to his/her asthma while at school?
(check all that apply and describe briefly)
Modify physical education class _____________________________________________
Modify outside recess _____________________________________________________
Special considerations on field trips __________________________________________
Observation for side effects from medication ___________________________________
Other __________________________________________________________________
Parent Signature _____________________________________ Date ___________________