How to answer the childhood asthma control form
Let your child answer the first four Asthma Control questions. If your child needs help reading or understanding the question, you may help, but let your child choose which answer he / she prefers. Complete the remaining three Asthma Control questions on your own without letting your child’s response influence your answers. There are no right or wrong answers.
Ask your child to complete these questions:
How is your asthma today?
How much of a problem is your asthma when you run, exercise or play sports?
Do you cough because of your asthma?
Do you wake up during the night because of your asthma?
Please complete the following questions on your own:
During the last 4 weeks, how many days did your child have any daytime asthma symptoms?
During the last 4 weeks, how many days did your child wheeze during the day because of asthma?
During the last 4 weeks, how many days did your child wake up during the night because of asthma?
If your score is between 0 and 12:
If your child’s score is 12 or less, their asthma may be very poorly controlled. Please contact the practice to arrange a review as early as possible. Your doctor or nurse may recommend an asthma action plan to improve this.
If your score is between 13 and 20:
Your child’s asthma may not be as well controlled as it should be. Your doctor or nurse may recommend an asthma action plan to improve this.
If your score is between 21 and 27:
Your child’s asthma control appears to be under control over the last 4 weeks.
However, if your child is experiencing any symptoms or you have any queries, please add them in to the box at the end of this form.
Please complete the additional questions below and then submit your review.
Please select the types of inhalers that you use:
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):