CHILDREN S HEALTH SURVEY

Transcription

1 CHILDREN S HEALTH SURVEY FOR ASTHMA CHILD VERSION The purpose of this survey is to find out how much asthma affects the everyday life of both you and your family. THERE ARE NO RIGHT OR WRONG ANSWERS!! American Academy of Pediatrics

2 PART I: YOUR HEALTH These questions ask about your health and medical care during the past 2 weeks. Please think about the past 2 weeks when you answer these questions. 1. During the past 2 weeks, how many s have you had wheezing? (Use your best guess)... Times 2. During the past 2 weeks, how many s have you had an asthma attack, or trouble breathing when you needed rest or extra medical care (such as more medicines or trips to the doctor)?... s 3. During the last 2 weeks, how many s did you go to a doctor because of your asthma?... s 2

3 4. During the past 2 weeks, how much have you had any se things because of your asthma? (Put an X in one circle on each line) None Little Of the Time Some Most All a. Shortness of breath b. Tightness in the chest c. Wheezing without a cold d. Cough e. A cold that won't go away f. Wheezing with a cold g. Difficulty sleeping (such as trouble falling to sleep, waking in the night coughing, or short of breath) 3

4 5a. Do you use medicine for your asthma? Yes... 1 No... 2 I don t know... 3 (Circle ONE) 5b. If yes, how often do you use medicine for your asthma? (Circle ONE) Everyday... 1 A few s per week... 2 Only with symptoms (shortness of breath, tightness in chest, wheezing, cough) Have you ever been taken to the emergency room for asthma? (Circle ONE) Yes... 1 No... 2 I don t know During the past two weeks, have you used an inhaler? (Circle ONE) Yes... 1 No... 2 I don t know

5 PART II: YOUR ACTIVITIES The next questions are about going to school and doing other things. 8. During the past 2 weeks, how many days of school did you miss because of your asthma? days CHECK THIS BOX IF YOU ARE ON SUMMER VACATION 9. During the past 2 weeks, how much did asthma keep you from doing these things? (Put an X in one circle on each line) Not at all A little bit Some A lot Totally a. School gym classes b. Sports or running outside c. Playing at friends, neighbors or relatives houses 5

6 10. During the past 2 weeks, how much did asthma keep you from doing these things? (Put an X in one circle on each line) a. Things that use a lot of energy or action such as running fast or playing hard Not at all A little bit Some A lot Totally b. Things that use some energy or action such as shooting hoops, bike riding, walking up stairs, or jumping rope c. Things that use a little energy or action such as walking 6

7 PART III: YOUR FEELINGS 11. During the past 2 weeks, how much did these things describe you because of your asthma? (Put an X in one circle on each line) None Little Some Most All a. I am frustrated about having asthma b. I feel left out by other people because of asthma c. I am sad d. I am embarrassed about having to use an inhaler (puffer) in school e. I am frustrated about having to use asthma treatments (medicine and/or inhaler) f. I am frustrated that I can t do some things because of asthma g. I am upset about having asthma h. I am upset by having to use asthma treatments 7

8 12. During the past 2 weeks, how much do you agree or disagree with these things about asthma? (Put an X in one square on each line) a. My asthma causes stress in my family Strongly Disagree Disagree Not Sure Agree Strongly Agree b. I am frustrated that other people don't understand what it is like to have asthma c. Somes I get angry and ask "why is this happening to me?" d. I know which medicines to take for my asthma 8

9 PART IV: ABOUT YOU Please tell us about yourself: 13. My birthday is: Month Day Year 14. I am a: Boy 1 Girl How old were you when you began to have wheezing, trouble breathing, or other asthma related problems? (Use your best guess) 16. Do you smoke? (Put an X in one circle) Yes 1 No Does anyone in your house smoke? (Put an X in one circle) Yes 1 No 2 9

10 18. Do you have pets? (Put an X in all circles that apply) No pets 1 Cat.. 2 Dog. 3 Bird.. 4 Other type of pet (specify ) Do any se things make your asthma problems worse? (Put an X in one circle on each line) Yes No Don t Know a. Colds b. Pets or other animals c. Dust d. Cigarette smoke e. Strong smells f. Exercise 10

11 20. What grade are you in this year in school? (If you are filling this out during summer vacation, what grade did you just finish?) (Put an X in one circle) 1 st grade 1 2nd grade 2 3 rd grade 3 4 th grade 4 5th grade 5 6th grade 6 7th grade 7 8th grade 8 9th grade (freshman) 9 10th grade (sophomore) 10 11th grade (junior) 11 12th grade (senior) 12 Home school (no grade assigned) Is there anything else you would like to tell us about what it s like for you to live with asthma? (Use the back of this page if you need more room) 11