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Revsurvey08

CHILD ASTHMA ASSESSMENT
SELF-ADMINISTERED BY PARENT OR GUARDIAN VERSION
Please do not complete the following form if:
1) You have completed this form in the past for this child

Asthma Symptoms (continued)
2) You have never been told by a doctor or health provider that your
5. During the past 4 weeks, before the time
child has asthma
your child’s asthma began to worsen, how 3) Your child is under 2 years of age or 18 years and older
much of the time did your child have difficulty Please check or fill in the answers to the following questions in
performing school activities, playing, or taking reference to your child. When finished, please return your completed
part in other regular daily activities as a result form to the staff member.
of [his/her] asthma? (SELECT ONE RESPONSE)
Asthma Medications
Asthma Medications

1. Prior to this Emergency Room visit, when did
your child’s asthma symptoms begin to worsen? 6. During the past 4 weeks, before the time
your child’s asthma began to worsen, how often did your child use albuterol, Alupent,Ventolin, Proventil, Maxair, ProAir, or Xopenex inhaler for 2. In the past 24 hours, including during the
albuterol, Alupent,Ventolin, Proventil, Maxair, ProAir, or Xopenex either by inhaler or nebulizer 3⅜6 to 9 times If answer to question 6 is“Did not use inhaler”,go to question 7.
6a. Before your child’s asthma worsened, how
long would you estimate that one canister of albuterol, Alupent,Ventolin, Proventil, Maxair, Asthma Symptoms
ProAir, or Xopenex lasted for your child? 3. During the past 4 weeks, before the time
your child’s asthma began to worsen, how 7. During the past 4 weeks, before the time
wheezing, shortness of breath, chest tightness, your child’s asthma began to worsen, how often did your child use albuterol by [his/her] 4. During the past 4 weeks, before the time
your child’s asthma began to worsen, how many 2⅜Almost every night nights did your child awaken due to coughing, wheezing, shortness of breath, chest tightness, 8. During the past 4 weeks, before the time
your child’s asthma began to worsen, did your child use inhaled or nebulized steroids such asFlovent, Pulmicort, Aerobid, Advair, Azmacort,Qvar, Symbicort or Asmanex for [his/her]asthma? Do not include pills or liquid.
If answer to question 8 is“No”,go to question 9.
IEDASP CHILD ASTHMA ASSESSMENT – PARENT/GUARDIAN – SELF VERSION 14.5, 06/12/08 Funding for the use and distribution of this survey was made possible by funds received from the
Illinois Department of Public Health, Office of Health Promotion and CDC grant #U59/CCU520891-01
Asthma Medications (continued)
Asthma Care
8a. During the past 4 weeks, how often did
15. During the past 4 weeks, how many times
your child take inhaled or nebulized steroids? did your child visit any doctor’s office or clinic for 16. Not including today’s visit, in the past 12
9. Does your child use cromolyn (also known as
months, how many times did your child visit any 1⅜1 time Intal) or nedocromil (also known as Tilade) for Emergency Room for problems with [his/her] If answer to question 9 is“No,” go to question 10. Otherwise continue with 9a.
17. In the past 12 months, how many times
9a. During the past 4 weeks, how often did
overnight or longer for problems with [his/her] your child use an inhaler or nebulizer to take 18. Was your child born a premature baby?
10. During the past 4 weeks, has your child
Physician or Nurse Contact
used Serevent, Foradil, Advair, or Symbicort? 19. Is there a doctor or nurse who your child
11. During the past 4 weeks, has your child
used any steroid pill or liquid medications If answer to question 19 is“No” go to question 20. Otherwise continue with 19a/b.
such as prednisone, pediapred, prednisolone, 19a. For this current asthma attack, did you
successfully contact your child’s doctor or nurse? 12. During the past 4 weeks, has your child
Asthma Medications (continued)
13. During the past 4 weeks, has your child
taken pill or liquid Theophylline, Aerolate, Elixophyllin, Quibron, Slo-Bid, Slo-phyllin,Theo-24,Theo-dur, or Uniphyl? 19b. Have you ever been given an asthma
questionnaire or survey by your child’s doctor or 14. During the past 4 weeks, has your child
taken pill or liquid albuterol, Proventil, Ventolin,Terbutaline, Brethine, Bricanyl, Isuprel,or Metaprel? Funding for the use and distribution of this survey was made possible by funds received from the
Illinois Department of Public Health, Office of Health Promotion and CDC grant #U59/CCU520891-01
General Information
20.
Is your child male or female?
21. What is your child’s age?
22. Is your child Spanish/Hispanic/Latino?
(SELECT ALL THAT APPLY. SELECT“NO” IF NOT 23. What best describes your child’s race/
ethnicity? (SELECT THOSE THAT APPLY.
Thank you for completing this survey.
Please give it to the staff member who will now
review this survey with you.
I have reviewed this survey and it is complete.
Funding for the use and distribution of this survey was made possible by funds received from the
Illinois Department of Public Health, Office of Health Promotion and CDC grant #U59/CCU520891-01

Source: http://www.iedasp.org/iedasp/ChildSurvey.612.pdf

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