Menu
Risk Profile
What Is Asthma
Risk Factors
Asthma Glossary
General
Completion Date
Child's Date of Birth
What is the child's name?
Self Assessment
What Grade is your Child in?
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Not in school
No Response
Do any of your child's parents, brothers, sisters, or grandparents have asthma?
Yes
No
No Response
All together, how many of these relatives have asthma?
Do you have a regular doctor or health care provider who treats your child's asthma? (Does not have to be an asthma specialist.)
Yes
No
No Response
During the past 12 months, when your child went to a doctor for asthma care, was it usually in an ER or clinic/doctor's office?
ER
Clinic/office
Both, mostly ER
Both, mostly clinic/office
Never had doctor's visit
No Response
Did your child usually see the same doctor at the clinic or office?
Yes
No
No Response
During the past 12 months, did your child take medicines for asthma?
Yes
No
No Response
Some asthma medicines are taken only when the child is having asthma signs or symptoms. Other medicines are taken even when the child is not having symptoms. Does your child take medicines only when having signs or symptoms, even when not having symptoms, or both times?
Only for symptoms
Only when no symptoms
Both
Has a doctor or health care provider ever given you written instructions for what to do about taking medicines?
Yes
No
No Response
Has your child had any problems taking medications at school?
Yes
No
No Response
Many people have problems making and keeping doctor's appointments for their child's asthma. At other times, it is hard to get to the office or they are not open at good times. In the past year, have you had any of these types of problems making or keeping appointments for your child's asthma?
Yes
No
No Response
Does your child's pillow have a zipped cover for allergies?
Yes
No
No Response
Does your child's mattress have a zipped cover for allergies?
Yes
No
No Response
Do you use a humidifier/vaporizer in your child's bedroom?
Yes
No
No Response
Do you have carpeting (or rugs) in your child's bedroom?
Yes
No
No Response
Do you have carpeting (or rugs) in your TV/family room?
Yes
No
No Response
Does your kitchen have a gas stove?
Yes
No
No Response
Do you sometimes use the gas stove to help heat your house?
Yes
No
No Response
Is there any moisture or mildew anywhere in your house in the following locations? (Check the box only if moisture or mildew is present.)
Ceiling
Walls
Windows
Have you had any problems with any of the following pests in your house? (Check the box only if the pest is present.)
Cockroaches
Mice
Rats
Do you have any of the following pets? (Check the box only if the pet is present.)
Dogs
Cats
Hamsters, Guinea Pigs, or Rabbits
Do you smoke cigarettes?
Yes
No
No Response
Does your child smoke cigarettes?
Yes
No
No Response
How many other people who live in your home smoke?
Does anyone else who takes care of your child smoke?
Yes
No
No Response
Have you ever run out of medicines for your child's asthma and not had any on hand when your child had an asthma attack?
Yes
No
No Response
For many reasons, children do not always get their medicines exactly when they are supposed to. On a scale of 1 to 5, how many problems do you usually face when trying to be sure your child gets his/her medicines? [1 is no problems with medicines and 5 is a lot of problems with medicines.]
1-No problems
2
3
4
5-A lot of problems
No Response
On a scale of 1 to 5, how would you rate your child's experience with taking his/her medicines exactly on schedule? [1 means never missing a dose of medicine and 5 means often missing a dose of medicine.]
1-Never misses a dose
2
3
4
5-Often misses a dose
No Response
Does your child take asthma medication on his/her own? Would you say…
Not at all
Once in a while
Quite a bit
All of the time
No medications
No Response
Are you concerned about your child's behavior or emotions?
Not at all
Once in a while
Quite a bit
All of the time
No Response
Do you have any concerns about how you have been coping with things in the past few months?
Not at all
Once in a while
Quite a bit
All of the time
No Response
Have you been feeling unusually stressed lately?
Not at all
Once in a while
Quite a bit
All of the time
No Response
Instruction: For the next 5 questions, please indicate whether you agree or disagree with the statement.
It is possible to control my child's asthma so that he/she can play like other children.
Strongly agree
Agree
Disagree
Strongly disagree
No Response
It is possible to manage my child's asthma so he/she is free of symptoms.
Strongly agree
Agree
Disagree
Strongly disagree
No Response
My child should not have problems from the asthma medicine he/she takes.
Strongly agree
Agree
Disagree
Strongly disagree
No Response
I have little control over my child's asthma.
Strongly agree
Agree
Disagree
Strongly disagree
No Response
I often feel helpless in dealing with my child's asthma.
Strongly agree
Agree
Disagree
Strongly disagree
No Response