Your child s name: Today s Date: When was your child s last asthma visit?. If your child has never had an asthma visit, check here:

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1 Communicate with Your Child s Doctor about His / Her Asthma Asthma also includes reactive airway disease, regular coughing, wheezing, or difficulty breathing with or without colds. Your child s name: Today s Date: When was your child s last asthma visit?. If your child has never had an asthma visit, check here: Please check one answer for each of the following questions. Your answers will help your doctor give you the best asthma care. Questions 1-6 ask about how your child s asthma has been over the past 12 months, not just today. If your child has had asthma for less than 12 months, then think about how things have been since he/she started having breathing problems. Over the past 12 months 1. How has your child s asthma been? Getting Better Over the past 12 months 2. How much have you been bothered by Not your child s asthma? Bothered Direction Staying the Same Bothered Somewhat Bothered Getting Worse Very Bothered Over the past 12 months Risk Before today: How many times has your child been to urgent care for asthma over the past 12 months? 4. How many times has your child been to the emergency room for asthma over the past 12 months? 5. How many times has your child been hospitalized for asthma over the past 12 months? 6. How many times has your child used an oral steroid (Orapred, steroid pill, steroid liquid or steroid syrup) for asthma over the past 12 months? Don t include today. FOR CLINICIAN USE ONLY: Assign patient s level of chronic asthma control by looking at the box checked farthest to the right on questions 3-6. Match the box color to the level of asthma control in this section. Take Medicine 7. How often do you give your child s daily asthma medicine when he/she feels fine? Daily asthma medicines include: Advair, Alvesco, Asmanex, Budesonide, Flovent, QVAR, Pulmictort, Singular, Symbicort My child is not supposed to take a daily asthma medicine Controlled All of the time 5-7 days/week Partly Controlled Mildly Uncontrolled Most of the time 3-4 days/week Moderately Uncontrolled Some of the time 1-2 days/week Severely Uncontrolled None of the time FOR CLINICIAN USE: If any of the answers in red are selected, this may be consistent with poorly controlled and/or undertreated asthma. Further assessment and follow-up in 2-6 weeks is recommended.

2 Sub-Acute Asthma These questions are about your child s recent asthma symptoms. 8. During the past week, how many days has your child had asthma symptoms? For example: *Cough *Chest tightness *Shortness of breath *Sputum (spit, mucous, phlegm when coughing) *Difficulty taking a deep breath *Wheezy or whistling sound in the chest 9. During the past week, how many have you had to give your child medicine to quickly relieve asthma symptoms? For example: *Albuterol/Proventil/Proair/Ventolin/Xopene z via Inhaler/Spray/Pump or Machine/Nebulizer 10. During the past week, how many days did your child have an asthma attack? For example: *When it is harder for child to breath *When you give your child more quick-relief asthma medicine (e.g., Albuterol) *When asthma medicine does not work 11. During the past week, how much has asthma limited your child s activities? Not at all Days Days Slightly Asthma Symptoms Reliever Use Attacks Days Every day (not all day long) Every day (not all day long) 2-3 Activity Limitation Moderately Very much Every day (all day long) Every day (all day long) 4-7 Completely 12. During the past TWO weeks, how many nights did your child s asthma keep your child from sleeping or wake him/her up? 0 1 Nighttime Symptoms Please write down any concerns or anything else you would like your doctor to know about your child s asthma. PLEASE GIVE THIS TO YOUR PROVIDER. THANK YOU! FOR CLINICIAN USE ONLY: Control/Severity Assignment: Assign patient s current level of asthma control by looking at the box checked farthest to the right on question 8-12 and match the box color to the level of asthma control in this section Sub-Acute Asthma Severity / Control Classification Partly Controlled/ Uncontrolled / Mild Persistent Moderate Controlled/ Intermittent Poorly Controlled/ Severe

3 Asthma History Family Medical History 1. Please indicate which family members have asthma, eczema, and/or seasonal allergies or hayfever: Asthma Season Allergies / hayfever Eczema Don t know Biological Mother Biological Father Brother(s) or Sister(s) Other family member(s) (aunts, uncles, cousins, etc.) Asthma History 2. Has your child s chest ever sounded wheezy or whistling? No Don t know Yes. How frequently do you or did year this sound? Very rarely Few days of the week Some days of the week Many days of the week On most days of the week 2a. Did you hear this wheezing or whistling sound before he/she was 4 years old? Yes No N/A (my child is less than 4 years old) Don t know 3. Has your child ever been diagnosed with asthma? No Don t know Yes. At what age? Less than Other age: years 4. How many times has your child spent the night in a hospital to be treated specifically for asthma? Never hospitalized or more times Don t know Other: times 5. How many times has your child been cared for in an intensive care unit (ICU) or been intubated (requiring a breathing tube) for asthma? Never Don t know Other: times

4 Allergy Profile 6. Has your child been previously tested for any form of allergy? No Don t know Yes If your child s allergy tests did not show any allergies, check (x) here If your child s allergy tests did show allergies, what are they? Check all that apply (below). Environmental Allergies Food Allergies Cat Grass Weeds Egg Milk/Dairy Cockroach Latex Ragweed Fruits Peanut Dog Mold Trees Shellfish Dust mite Mouse Other positive allergy test results (describe, below) General Past Medical History Please place an x or check to select your answer for each question. Birth History 1. During the pregnancy, did the child s mother have any of the following problems? (Check all that apply) Early labor (before 37 weeks) High blood pressure High blood sugar An infection None of these Don t know 2. During the pregnancy, did the child s mother use: (Check all that apply) Cigarettes Alcohol Drugs (e.g., methadone, cocaine, marijuana) None of these Don t know 3. Was your child born on time? Yes (37-42 weeks gestation) Don t know No how many weeks gestation? (Choose below) 22 weeks 27 weeks 32 weeks 23 weeks 28 weeks 33 weeks 24 weeks 29 weeks 34 weeks 25 weeks 30 weeks 35 weeks 26 weeks 31 weeks 36 weeks 4. How was this child born? Vaginal Cesarean section Don t know

5 5. How much did your child weight when he/she was born? Please write-in pounds or grams. Don t know pounds ounces grams Other: 5 Other: What is the birth order of your child? 1st 2nd 3rd Other Don t know Out of how many children? Other: 7. How long did this child stay in the hospital before going home? less than 48 Don t know days weeks hours 8. Did your child need help from a breathing machine (e.g., respirator, CPAP) to breathe after he/she was born? No Don t know Yes- for how many days, weeks, or months? What type of breathing machine? days weeks months ventilator/respirator nasal CPAP High-flow oxygen/ SiPAP Don t know Other: 9. Did this child require extra oxygen to help with breathing after he/she was born? No Don t know Yes- for how many days, weeks, or months? days weeks months

6 Feeding History 10. Did this child breast feed? No Don t know Yes, for how many months? months Other: months Medical Complications 11. Has your child has any of the following medical problems? (please check all that apply): Failed hearing screen Poor weight gain Snoring Other problems (describe below) None of these Don t know Other medical problem #1 Other medical problem #2 Surgical History 12. Has your child ever had a surgery? No Don t know Yes. What surgery? Check all below that apply: adenoidectomy Nissen fundoplication Tracheoesophageal fistula (TEF) tonsillectomy tracheostomy Other type of surgery (describe below) Other surgery sinus surgery tympanostomy/ PE tubes cleft palate/lip feeding tube VP shunt spine Other surgery Breathing Problems 13. Has your child ever spent the night in a hospital to be treated for breathing problems (e.g., RSV, bronchiolitis, asthma, low oxygen levels, pneumonia)? No Yes. How many times? more than 5 times Other: times Don t know

7 14. Has your child ever taken a swallowed steroid by mouth (for example, prednisone, prelone, OraPred) to treat a breathing problem? See pictures below. No Yes. How many times? more than 5 times Other: times Don t know 15. What trigger your child s breathing problems (e.g., wheezing, cough, noisy breathing)? Check all that apply: aspirin/ ibuprofen cold air summer season None of these dust changes in weather exercise Others. Describe below grass hot weather colds/respiratory viruses Don t know trees changes in season sinus infections molds fall season allergy/ hayfever symptoms tobacco smoke spring season cats fumes or perfumes winter season dogs Other triggers #1 Other triggers #2 16. How often has your child missed school, pre-school, or child care because of breathing problems (e.g., wheezing, cough, noisy breathing)? Never Less than 5 days per year 5 to 10 days per year More than 10 days per year My child is not is school or daycare Don t know Environmental History Form 1. Is your child currently in school, child care, or pre-school? Yes No Don t Know

8 2. Is your home a: single family house rowhouse townhouse apartment mobile home Other: 3. Does your home have: (check all that apply) central of forced warm air heating damp areas plants radiator heating cockroaches birds central air-conditioning mice hot tub/ jacuzzi window air-conditioning unit cat(s) How many? wood-stove humidifier dog(s) How many? None of these 4. Does your child s bedroom have (check all that apply): wall-to-wall carpet hardwood floors area rugs stuffed toys None of these 5. Does your child use (check all that apply): dust mite-proof pillow covers dust mite-proof bed covers None of these Smoking History 6. How is cigarette smoking handled as far as your home is concerned? Smoking is not allowed in the home Smoking is sometimes allowed in the home Smoking is always allowed in the home 7. Please indicate the smoking status of each of the following people/places your child may be present. Mother Father Any Other Relative Daycare (e.g., aunt, uncle, provider grandparent, etc.) Does this person live with your child? Yes No Yes No Yes No Is this person a CURRENT SMOKER? Yes No Yes No Yes No Yes No

9 Sociodemographics Form 1. Is your child a boy or a girl? boy girl 2. What is your child s birth date? / / Month Day Year 3. What is your relationship to the child? Biological mother Adoptive mother Biological father Grandmother Grandfather Adoptive father Legal guardian Other, please specify: 4. Is there another parent or primary caregiver? Yes No (skip to question 6) 5. If so, what is his/her relationship to the child? Biological mother Adoptive mother Biological father Grandmother Grandfather Adoptive father Legal guardian Other, please specify: 6. How many children do you have? 7. What is your marital status? 0 4 Married Widowed 1 5 Separated Single, living with significant other 2 6 Divorced Single, not living with significant other 3 7 or more 8. Please indicate the highest level of education COMPLETED. You Other caregiver Less than high school High school graduate 2-year college or technical school 4-year college graduate Any post-graduate study Don t know

10 9. Please indicate the current work situation of you and your child s other caregiver. You Other caregiver Working at a paying full-time job Working at a paying part-time job Not working, but looking for a paying job Disabled Retired Full-time homemaker Working at a temp job/day laborer Other 10. In general, what language(s) does your family speak at home? English only Spanish more than English Spanish only English more than Spanish English and another language: Only another language (specify): both Spanish and English 11. How would you describe the ethnicity of this child and his/her biological parents? Please check all that apply. child biological mother biological father White/Caucasian Black/African-American Black, not African-American Hispanic/Latino (specify): American Indian/Native Alaskan Pacific Islander/Native Hawaiian Don t know Other race/ethnicity (specify): 12. How long have you lived in the United States? all my life not all my life, years 13. If you have not lived in the United States all your life, what is your country of origin?