Just answer yes or no to these questions.
2. When I walk up hills or stairs, I have trouble breathing or I cough. Yes__ No__
3. I don't like to run or play sports because I have trouble breathing or I cough. Yes__ No__
4. Sometimes I wake up at night with coughing or trouble breathing. Yes__ No__
5. Sometimes I have trouble taking a deep breath. Yes__ No__
6. Sometimes I make wheezing sounds in my chest. Yes__ No__
7. Sometimes my chest feels tight or hurts. Yes__ No__
8. Sometimes I cough a lot. Yes__ No__
9. Being outdoors or around dust or pets makes my breathing worse. Yes__ No__
10. It's hard to breathe in cold weather. Yes__ No__
11. It's hard to breathe when people smoke or there are strong odors. Yes__ No__
12. Colds make me cough or wheeze. Yes__ No__
13. I went to the doctor's office or emergency room for asthma or trouble breathing this year. Yes__ No__
14. I stayed in the hospital overnight for asthma or trouble breathing this year. Yes__ No__
15. I've been told that I have asthma. Yes__ No__
If you answered "no" to number 15, you have completed the Asthma Check. If you answered "yes," please answer questions 16-21.
16. I use my asthma inhaler two or more times a week. Yes__ No__
17. Sometimes my asthma medicine makes me feel bad. Yes__ No__
18. I only take medicine when I don't feel well. Yes__ No__
19. I can't do some things because of my asthma. Yes__ No__
20. I get scared because of my asthma. Yes__ No__
21. I worry that I may die from my asthma. Yes__ No__
"Yes" answers to more than one of these questions may indicate that the child has asthma. Further testing is recomended. Print-out this form and bring it with you to see your family physician.