Child asthma review

Section

Height:

In cm

Weight:

In kg

Does someone you live with smoke?

Yes

No

Child Asthma Control Questions

What inhaler(s) does your child have?

How often does your child use each inhaler at present?

What colour preventer do you use:

For example, brown, red, white

How many puffs per day:

How many times per day:

I have taken steroid tablets (prednisolone) for my asthma in the last year:

Yes

No

I have used a nebuliser for my asthma in the last year:

Yes

No

A nebuliser is an electric machine that creates a mist of medicine you breathe in

I have seen someone other than Brookside, or my pharmacy, for my asthma in the last year:

Yes

No

Please explain who else you have seen for your asthma:

I am confident I know how to use my inhaler:

Yes

No

Child Asthma Control Test – Child Answers

The child should answer these questions

How is your asthma today?

Very bad – 0

Bad – 1

Good – 2

Very good – 3

How much of a problem is your asthma when you run, exercise or play sports?

It’s a big problem, I can’t do what I want to do – 0

It’s a problem and I don’t like it – 1

It’s a little problem but it’s ok – 2

It’s not a problem – 3

Do you cough because of your asthma?

Yes, all of the time – 0

Yes, most of the time – 1

Yes, some of the time – 2

No, none of the time – 3

Do you wake up in the night because of your asthma?

Yes, all of the time – 0

Yes, most of the time – 1

Yes, some of the time – 2

No, none of the time – 3

Child Asthma Control Test – Parent/Guardian Answers

The parent/guardian should answer these questions

During the last 4 weeks, how many days did the child have daytime asthma symptoms?

During the last 4 weeks, how many days did the child wheeze during the day because of asthma?

During the last 4 weeks, how many days did the child wake up during the night because of asthma?

Total score:

Out of 27

Additional questions

Over the past year, has your child had times when asthma symptoms have appeared every week?

Yes

No

For example, cough, wheeze, shortness of breath, waking at night, symptoms with or after exercise, needing to use a reliever inhaler

Please give details:

Do you know what triggered these symptoms?

Do you have any questions or concerns about your child’s asthma?

Yes

No