12 and older: IF YOUR CHILD HAS ASTHMA, pls answer this form; IGNORE if no Asthma

This form is for 12 years old and older only, please use the other form if you child is 11 years old or younger. Este formulario es solo para mayores de 12 años, use el otro formulario si su hijo tiene 11 años o menos.
Name of Patient/ Nombre de Paciente*

First NameLast Name
Date of birth*

MonthDayYear
Date
Date of Appointment*

MonthDayYear
Date
Total Score
1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?*

1 - All the time2 – Most of the time3 – Some of the time4 – A little of the time5 – None of the time
2. During the past 4 weeks, how often have you had shortness of breath?*

1 – More than once a day2 – Once a day3 – three to six times a week4 – once or twice a week5 – Not at all
3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness orpain) wake you up at night or earlier than usual in the morning?*

1 – FOUR or more nights a week2 – TWO TO THREE nights a week3 – Once a week4 - Once or twice a month5 – Not at all
4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?*

1 - THREE or more times per day2 – One to two times per day3 - Two to three times per week4 – Once a week or less5 – Not at all
5. How would you rate your asthma control during the past 4 weeks?*

1 - Not controlled at all2 – Poorly controlled3 – Somewhat controlled4 – Well controlled5 – Completely controlled
Should be Empty:

This form is for 12 years old and older only, please use the other form if you child is 11 years old or younger. Este formulario es solo para mayores de 12 años, use el otro formulario si su hijo tiene 11 años o menos.