Asthma School Survey 2005
Identification
School Number
A
B
C
D
Select one
Student ID #
Parent School Asthma Pre-Interventation Survey
Personal Information
Gender
Female
Male
Select one
Child's First Name
Child's Last Name
Child's Date of Birth
(Required)
mm-dd-yyyy
Age
(Read Only)
##
Zip Code
Your Last Name
Your First Name
Relationship to Child
Home Phone Number
###-###-####
PS School Number
(Read Only)
Grade
##
Today's Date
mm-dd-yyyy
Medical Information
Asthmatic Conditions
Has a health professional ever told you that your child has any of the following conditions?
Asthmatic Bronchitis or Wheezy Bronchitis
Asthma
Reactive Airway Disease
Wheezing
Has a health professional prescribed any medication to your child?
Yes
No
Select one
How many times did your child have an emergency visit for breathing problems?
##
How many times did your child have to stay overnight in the hospital for breathing problems?
##
Does your child take medicine every day for breathing difficulties?
Yes
No
Select one
Select the month when your child's breathing was the worst?
January
February
March
April
May
June
July
August
September
October
November
December
Select one
Asthma Symptoms
Monthly Breathing Difficulties
During their worst breathing month, select how often the following symptoms occurred?
Wheeze or whistling in the chest?
Never
2 times each week or less
3 to 6 times each week
Every day but not all day
Every day and all day
Select one
Have a cough?
Never
2 times each week or less
3 to 6 times each week
Every day but not all day
Every day and all day
Select one
Have a tight chest or shortness of breath?
Never
2 times each week or less
3 to 6 times each week
Every day but not all day
Every day and all day
Select one
Wake up at night from wheezing, coughing, or trouble breathing?
Never
2 times each week or less
3 to 6 times each week
Every day but not all day
Every day and all day
Select one
How many days of school has your child missed due to asthma?
###
Have breathing problems stopped your child from participating in sports?
Yes
No
Select one
If Yes, how many times in the past month?
2 times a month or fewer
3 to 4 times a month
1 to 3 times each week
4 times each week or more
Select one
How many people living in the home, including this child, have asthma?
##
Record Unique Identifier
Record is completed
Record is flagged
Data Not Saved