Do any of your child's parents, brothers, sisters, or grandparents have asthma?

Yes No No Response

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?

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?

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.]

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.]

Does your child take asthma medication on his/her own? Would you say…

Are you concerned about your child's behavior or emotions?

Do you have any concerns about how you have been coping with things in the past few months?

Have you been feeling unusually stressed lately?

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.

It is possible to manage my child's asthma so he/she is free of symptoms.

My child should not have problems from the asthma medicine he/she takes.