Asthma Questionnaire

Asthma questionnaire is a compilation of questions which is used to diagnose people, especially small children with asthma. This is carried out by doctors, pediatricians and hospitals to find out the severity of condition among a patient apart and also suggest remedial measures.

Asthma Questionnaire Sample

Patient’s Name:          ______________________________________________________

Date of birth:                     __________/_____________/_________________

Gender:                     _________________________________________

Address:                    ______________________________________________________

____________________________ Zip Code:   ____________

Name of the person filling this form:        ________________________________________________

Contact Nos:                      _______________       _________________       ________________

Landline                       Work                 Cell

1. How often do you find the patient coughing, panting, puffed or having breathing problems during morning hours?
   1. This happens less than once in a week
   2. Happens more than once in a week
   3. Happens daily
   4. Happens continuously

1. How often do you find the patient coughing, panting, puffed or having breathing problems during night hours?
   1. This happens less than once in a week
   2. Happens more than once in a week
   3. Happens daily
   4. Happens continuously

1. Does any physical activity cause the patient coughing, panting or experience breathing problem?
   1. No or very rarely
   2. It happens sometimes
   3. It happens quite often
   4. It does happen almost always

1. Does the patient rely on the use of an inhaler or nebulizer to remedy these problems?
   1. Rarely with exercise
   2. More than 4-5 times in a month
   3. It is being used daily
   4. It is used multiple times in a day

1. Is the patient unable to participate in any outdoor activities or sport because of his breathing problems?

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1. Does the patient miss school/college/office because of breathing problems? How many times did this happen in the last year?

________________________________________________________________________________________________________________________________________________

1. Do the patient’s family members miss their work because of his breathing problems? How many times did this happen in the last year?

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