Asthma questionnaire

Asthma Questionnaire

Please use this form to answer questions about your Asthma.

Name  Required
Date of Birth  Required
Current smoking status  Required
During the past 4 weeks, how often did your asthma prevent you from getting as much done at work, school or home?  Required
During the past 4 weeks, how often have you had shortness of breath?  Required
During the past 4 weeks, how often did your asthma symptons (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?  Required
During the past 4 weeks, how often have you used your reliever inhaler (usually the blue inhaler) or nebuliser medication?  Required
How would you rate your asthma control during the past 4 weeks?  Required

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