Child Asthma Review

If you have been advised by the surgery to submit an annual review of your asthma symptoms please use this form. If your symptoms are deteriorating or you are having any concerns please make an appointment with our Nurse.

To ensure you are using your inhaler correctly please visit:

• www.asthma.org.uk

You can also watch a short video to improve your inhaler technique at:

• www.asthma.org.uk/inhalervideos

Child Asthma Review

Child Asthma Review

If you are human, leave this field blank.

About You

First Name: *

Of child.

Surname: *

Of child.

Date of Birth: *

Of child. Please use this date format: DD/MM/YYYY.

Phone Number:

Of parent/guardian.

Email Address: *

Of parent/guardian.

Height:

In cm.

Weight:

In kg.

Does someone you live with smoke?

Yes

No

Child Asthma Control Questions

I only use a blue inhaler:

Yes

No

What colour preventer do you use:

Eg. 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?

Everyday - 0

19-24 days - 1

11-18 days - 2

4-10 days - 3

1-3 days - 4

Not at all - 5

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

Everyday - 0

19-24 days - 1

11-18 days - 2

4-10 days - 3

1-3 days - 4

Not at all - 5

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

Everyday - 0

19-24 days - 1

11-18 days - 2

4-10 days - 3

1-3 days - 4

Not at all - 5

Total score:

Out of 27.