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Communicate with Your Child’s Doctor About His/Her Asthma
Asthma also includes reactive airway disease, regular coughing, wheezing, or difficulty breathing with or without colds.
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Your child’s name:
Today’s Date:_______________________
When was your child’s last asthma visit? ____________If your child has never had an asthma visit, check here:
Please check one answer for each of the following questions. Your answers will help your doctor give you the best
asthma care.
Questions 1-5 ask about how your child’s asthma has been over the past 12 months, not just today. If your child
has had asthma for less than 12 months, then think about how things have been since he/she started having
breathing problems.
Over the past 12 months
1. How has your child’s asthma been?
Over the past 12 months
2. How much have you been bothered
by your child’s asthma?
Direction
Getting
Better
Staying
The Same
Getting
Worse
Bothered
Not
Bothered
Over the past 12 months
Before today:
3. How many times has your child been to
urgent care for asthma?
Somewhat
Bothered
Very
Bothered
Risk
0
1
2
3
≥4
4. How many times has your child been to
the emergency room for asthma?
5. How many times has your child been
hospitalized for asthma?
6. How many times has your child used an oral
steroid (Orapred, steroid pill, steroid liquid or
steroid syrup) for asthma? Don’t include today.
FOR CLINICIAN USE ONLY:
Assign patient’s level of chronic asthma control by
looking at the box checked farthest to the right on
questions 3-6. Match the box color to the level of
asthma control in this section.
Controlled
Partly
Mildly
Moderately
Severely
Controlled Uncontrolled Uncontrolled Uncontrolled
Take Medicine
7. How often do you give your
My child is not
child’s daily asthma medicine when supposed to take
All of
Most of
Some of
None of
he/she feels fine?
the
time
the
time
the
time
the
time
a daily asthma
Daily asthma medicines include:
5-7 days/week 3-4 days/week 1-2 days/week
medicine
Advair, Alvesco, Asmanex,
Budesonide, Flovent, QVAR,
Pulmicort, Singulair, Symbicort
PLEASE TURN OVER
FOR CLINICIAN USE: If any of the answers in red
are selected,
this may be consistent with poorly controlled and/or undertreated asthma.
Further assessment and follow-up in 2-6 weeks is recommended.
Sub-Acute Asthma
These questions are about your child’s recent asthma symptoms.
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Asthma Symptoms
Days
8. During the past week, how many
days has your child had asthma
symptoms? For example:
*Cough
*Chest tightness
*Shortness of breath
*Sputum (spit, mucous, phlegm when coughing)
*Difficulty taking a deep breath
*Wheezy or whistling sound in the chest
0
1-2
3-6
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Every day
Every day
(not all day long) (all day long)
Reliever Use
Days
9. During the past week, how many
days have you had to give your child
medicine to quickly relieve asthma
symptoms? For example:
*Albuterol/Proventil/Proair/Ventolin/Xopenex
via Inhaler/Spray/Pump or Machine/Nebulizer
0
1-2
3-6
Every day
Every day
(not all day long) (all day long)
Attacks
10. During the past week, how many
days did your child have an asthma
attack? For example:
*When it is harder for your child to breathe
*When you give your child more quick-relief
asthma medicine (e.g., Albuterol)
*When the asthma medicine does not work
Days
0
1
2-3
4-7
Activity Limitation
11. During the past week, how
much has asthma limited your
child’s activities?
Not at all
Slightly Moderately Very much
Completely
Nighttime Symptoms
12. During the past TWO weeks, how many
nights did your child’s asthma keep your
child from sleeping or wake him/her up?
0
1
2
3-7
8-14
13. Please write down any concerns or anything else you would like your doctor to know about your child’s asthma.
PLEASE GIVE THIS TO YOUR PROVIDER. THANK YOU!
FOR CLINICIAN USE ONLY:
Control/Severity Assignment:
Sub-Acute Asthma Severity/Control Classification
Assign patient’s current level of asthma control
by looking at the box checked farthest to the
Controlled/
Partly Controlled/
right on questions 8 – 12 and match the box
Intermittent
Mild Persistent
color to the level of asthma control in this section.
Uncontrolled/ Poorly Controlled/
Moderate
Severe
35078
Date:
/
Study ID:
/
Asthma History
Family Medical History
1. Please indicate which family members have asthma, eczema and/or seasonal
allergies or hayfever.
Asthma
Seasonal Allergies/
hayfever
Eczema
Don't Know
Biological Mother
Biological Father
Brother(s) or Sister(s)
Other family member(s)
(aunts, uncle, cousins, etc.)
Asthma History
2. Has your child's chest ever sounded wheezy or whistling?
No
Don't Know
Yes. How frequently do you or did you hear this sound?
very rarely
few days of the week
some days of the week
many days of the week
on most days of the week
Did you hear this wheezing or whistling sound before he/she was 4 years old?
Yes
No
N/A (my child is less than 4 years old)
Don't know
3. Has your child ever been diagnosed with asthma?
No
Don't Know
Yes- at what age?
Less than 1
1
2
3
4
5
6
other age:
years
35078
4. How many times has your child spent the night in a hospital to be treated
specifically for asthma?
Never hospitalized
1
2
3
4
5
more than 5 times
Don't Know
Other
times
5. How many times has your child been cared for in an intensive care unit (ICU) or
been intubated (require a breathing tube) for ashtma?
Never
1
2
3
4
5
Don't Know
Other
times
Allergy Profile
6. Has your child been previously tested for any form of allergy?
No
Don't Know
If your child's allergy tests did not show any allergies, check (x) here
If your child's allergy tests did show allegies what are they? Check all that apply
(below):
Food Allergies
Environmental Allergies
Cat
Grass
Cockroach
Dog
Weeds
Latex
Mold
Dustmite
Trees
Egg
Ragweed
Milk/Dairy
Fruits
Peanut
Shellfish
Mouse
Other positive allergy test results (describe, below)
Other allergy test #1
Other allergy test #2
Other allergy test #3
Yes
Date:
8819
/
Study ID:
/
For Office Use
General Past Medical History
Please place an "x" or check to select your answer for each question
Birth History
1. During the pregnancy, did the child's mother have any of the following problems?
(check all that apply):
early labor (before 37 weeks)
high blood pressure
an infection
Don't know
None of these
high blood sugar
2. During the pregnancy, did the child's mother use (check all that apply):
cigarettes
alcohol
drugs (e.g., methadone, cocaine, marijuana)
None of these
Don't know
3. Was your child born on time?
Yes (37-42 weeks gestation)
4. How was this child born?
Don't know
vaginal
No- how many weeks gestation (choose below):
22 weeks
27 weeks
32 weeks
23 weeks
28 weeks
33 weeks
24 weeks
29 weeks
34 weeks
25 weeks
30 weeks
35 weeks
26 weeks
31 weeks
36 weeks
cesarian section
Don't know
5. How much did your child weigh when he/she was born? Please write-in pounds or grams.
Don't know
pounds
1
1
6
2
7
3
8
4
9
5
Other
ounces
7
OR
2
8
14
3
9
15
4
10
Other
5
11
6
12
1st
6. What is the birth order of your child?
Out of how many children?
1
2
grams
13
3
2nd
4
5
3rd
6
Other
Other
Don't know
8819
7. How long did this child stay in the hospital before going home?
less than 48 hours
days
weeks
months
Don't know
8. Did your child need help from a breathing machine (e.g., respirator, CPAP) to
breathe after he/she was born?
No
Don't know
Yes- for how many days, weeks, or months?
days
weeks
What type of breathing machine?
ventilator/respirator
nasal CPAP
months
High-flow oxygen/SiPAP
Don't know
Other
9. Did this child require extra oxygen to help with breathing after he/she was born?
No
Don't know
Yes- for how many days, weeks, or months?
days
weeks
months
Feeding History
10. Did this child breast feed?
1
No
2
Don't know
3
4
5
Yes , for how many months?:
6 months
Other
months
Medical Complications
11. Has your child had any of the following medical problems? (please check all that
apply):
Failed hearing screen
None of these
Other medical
problem #1
Other medical
problem #2
Poor weight gain
Don't know
Snoring
Other problems (describe below)
8819
Surgical History
12. Has your child ever had a surgery?
No
Don't know
Yes. What surgery? Check all below that apply:
sinus surgery
adenoidectomy
tympanostomy/PE tubes
Nissen fundoplication
cleft palate/lip
Tracheoesophageal fistula (TEF)
feeding tube
tonsillectomy
VP shunt
tracheostomy
spine
Other type of surgery (describe below)
Other surgery
Other surgery
Breathing Problems
13. Has your child ever spent the night in a hospital to be treated for breathing
problems (e.g., RSV, bronchiolitis, asthma, low oxygen levels, pneumonia)?
No
Yes. How many times?
1
2
3
4
5
more than 5 times
Other
times
Don't know
14. Has your child ever taken a steroid by mouth (for example, prednisone, prelone,
OraPred) to treat a breathing problem?
No
1
Yes-how many times?
2
3
4
5
more than 5 times
Other
times
Don't know
8819
15. What triggers your child's breathing problems (e.g., wheezing, cough, noisy
breathing)? check all that apply:
None of these
aspirin/ibuprofen
cold air
summer season
dust
changes in weather
exercise
grass
hot weather
Don't know
colds/respiratory viruses
trees
changes in season
sinus infections
molds
fall season
allergy/hayfever symptoms
tobacco smoke
spring season
cats
fumes or perfumes
winter season
dogs
Others, describe below
Other triggers #1
Other triggers #2
16. How often has your child missed school or daycare because of breathing problems (e.g.,
wheezing, cough, noisy breathing)?
Never
Less than 5 days per year
My child is not in school or daycare
5 to 10 days per year
Don't know
More than 10 days per year
54155
Date:
/
Study ID:
/
For Office Use
Environmental History Form
Yes
1. Is your child currently in daycare or pre-school?
2. Is your home a:
single family house
rowhouse
No
townhouse
Don't Know
apartment
mobile home
Other
3. Does your home have: (check all that apply)
central or forced warm air heating
damp areas
plants
radiator heating
cockroaches
birds
central air-conditioning
mice
hot tub/jacuzzi
window air-conditioning unit
cat(s) How many?
wood-stove
humidifier
dog(s) How many?
None of these
4. Does your child's bedroom have (check all that apply):
wall-to-wall carpet
hardwood floors
area rugs
stuffed toys
None of these
5. Does your child use (check all that apply):
dust mite-proof pillow covers
dust mite-proof bed covers
None of these
Smoking History
6. How is cigarette smoking handled as far as your home is concerned?
Smoking is not allowed in the home
Smoking is sometimes allowed in the home
Smoking is always allowed in the home
54155
7. Please indicate the smoking status of each of the following people/places your
child may be present.
Any Other Relative
(e.g., aunt, uncle,
grandparent, etc.)
Daycare Provider
Mother
Father
Does this person
live with your
child?
Yes
Yes
Yes
No
No
No
Is this Person a
CURRENT SMOKER?
Yes
Yes
Yes
Yes
No
No
No
No
Please answer the following questions only if there is a smoker in the child's
home.
There are no smokers in the child's home.
8.
What do they
smoke and how
much?
When does
he/she smoke
in the home?
Does he/she
smoke on the
porch, in the
yard, in the
driveway, or
in the
garage?
Does he/she
smoke in the
car?
Mother
cigarettes
Father
cigarettes
Any Other Relative
(e.g., aunt, uncle,
grandparent, etc.)
ciagarettes
less than 1 pack a day
less than 1 pack a day
less than 1 pack a day
1 pack a day
1 pack a day
1 pack a day
more than a pack a day
more than a packa day
more than a pack a day
cigars
cigars
cigars
pipe
pipe
pipe
Don't know
Don't know
Don't know
N/A
N/A
N/A
daily or almost daily
daily or almost daily
daily or almost daily
sometimes
sometimes
sometimes
never smokes in home
never smokes in home
never smokes in home
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
No
9. How much effect do you think exposure to tobacco smoke has on your child's asthma?
No bad effect
A small bad effect
A moderate bad effect
A large bad effect
Today’s
Date:
Study ID #
Month
Day
Year
Sociodemographics Form
1. Is your child a boy or a girl?
boy
2. What is your childʼs birth date?
girl
Month
Day
Year
3. What is your relationship to the child?
Biological mother
Adoptive mother
Biological father
Adoptive father
Grandmother
Legal guardian
Grandfather
Other, please specify:
4. Is there another parent or primary caregiver?
yes
no (skip to question 6)
5. If so, what is his/her relationship to the child?
Biological mother
Adoptive mother
Biological father
Adoptive father
Grandmother
Legal guardian
Grandfather
Other, please specify:
6. How many children do you have?
0
4
1
5
2
6
3
7 or more
7. What is your marital status?
Married
Widowed
Separated
Single, living with significant other
Divorced
Single, not living with significant other
8. Please indicate the highest level of education COMPLETED.
you
other
caregiver
Less than high school
High school graduate
2-year college or technical school
4-year college graduate
Any post-graduate study
Donʼt know
PLEASE TURN OVER
9. Please indicate the current work situation of you and your childʼs other caregiver.
other
you
caregiver
Working at a paying full-time job
Working at paying part-time job
Not working, but looking for a paying job
Disabled
Retired
Full-time homemaker
Working at a temp job/day laborer
Other
10. In general what language(s) does your family speak at home?
English only
Spanish more than English
Spanish only
English and another language ______________________
English more than Spanish
Only another language (specify): ____________________
both Spanish and English
11. How would you describe the ethnicity of this child and his/her biological parents?
Please check all that apply.
biological
biological
child
mother
father
White/Caucasian
Black/African-American
Black, not African-American
Hispanic/Latino (specify) _____________________
American Indian/Native Alaskan
Asian/Asian-American
Pacific Islander/Native Hawaiian
Donʼt know
Other race/ethnicity (specify) __________________
12. How long have you lived in the United States?
all my life
years
13. If you have not lived in the United States all your life, what is your country of origin?