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Asthma Check from the American College of Allergy, Asthma & Immunology (ACAAI). 

 

Just answer yes or no to these questions.

1. When I walk or play hard with friends, I have trouble breathing or I cough. Yes__   No__

 

 

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.

 

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