Child asthma review

Child’s First Name: *

Child’s Surname: *

Your Full Name: *

Relationship to Patient: *

Your Phone Number: *

Your Email Address: *

How to answer the childhood asthma control form

Let your child answer the first four Asthma Control questions. If your child needs help reading or understanding the question, you may help, but let your child choose which answer he / she prefers. Complete the remaining three Asthma Control questions on your own without letting your child’s response influence your answers. There are no right or wrong answers.

Asthma Control

Ask your child to complete 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 is a big problem, I cannot do what I want to do – 0

It is a problem and I do not like it – 1

It is a little problem but it is okay – 2

It is not a problem – 3

Do you cough because of your asthma? *

Yes, all 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 during the night because of your asthma? *

Yes, all the time – 0

Yes, most of the time – 1

Yes, some of the time – 2

No, none of the time – 3

Please complete the following questions on your own:

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

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

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

Total Score:

If your score is between 0 and 12:

Off target

If your child’s score is 12 or less, their asthma may be very poorly controlled. Please contact the practice to arrange a review as early as possible. Your doctor or nurse may recommend an asthma action plan to improve this.

If your score is between 13 and 20:

On target

Your child’s asthma may not be as well controlled as it should be. Your doctor or nurse may recommend an asthma action plan to improve this.

If your score is between 21 and 27:

Well done

Your child’s asthma control appears to be under control over the last 4 weeks.

However, if your child is experiencing any symptoms or you have any queries, please add them in to the box at the end of this form.

Additional Questions

Please complete the additional questions below and then submit your review.

Additional Questions

Child’s current height:

Child’s current weight:

Child’s latest peak flow reading:

Is your child exposed to second hand smoke at home? *

Yes

No

Does your child have a personalised asthma action plan? *

Yes

No

Since your child’s last review, have they needed to see a doctor as an emergency or attend the A&E department of a hospital as a result of their asthma? *

Yes

No

Since your child’s last review, have they needed a course of steroid tablets to get their asthma under control? *

Yes

No